Month: October 2011

Why we must be anti-capital. 1.

Some within the environmental movement accept that capitalism is inimical to ‘saving the planet’. I tend to agree. To try and understand why this is, we first have to really understand how capitalism actually works. Understanding the process is a cool objective non-political analytical approach. One does not need to be political to understand how a bond market works, one may become political afterwards. Similarly, grasping the basic drive of capitalism does not require adherence to Marxist or neoliberal politics. What follows here is the analysis by David Harvey which can be found in his book: ‘The enigma of capital and the crises of capitalism’ (2010).

The first point to note is that capital is a process whereby ‘money is sent in search of more money’. It is not an evitable process, humans have used other economic processes (such as barter, subsistence) and could choose other economic systems. Capitalism (the economic system in which this process occurs) just happens to be dominant at this point in our history.

There are various ways in which the process of money searching for more money occurs:


1. Finance capital. I have lots of money and I will lend you some of it for a rate of interest. Banks in our current system have taken this to extremes. The money they have does not actually exist except as numbers on a computer screen. They then lend out to many others by making numbers appear on other computer screens. Doing this is easy because there is nothing actually to give, there is no concrete ‘thing’. So, ‘fractional reserve banking’ means I can take my £xbn and turn that into a bigger number on my screen and then ‘lend’ £100xbn to others and as long as this stays on computer screens we are ok. In addition, it does not rely on whomsoever gave the first £xbn not wanting their money back all at once. Governments and Banks (most is bank created) can just ‘create ’ money and lend (quantitative easing), they just almost literally press keys on a keyboard and hey presto another £75bn appears as if by magic! This form of capital flow has dominated the UK economy.

2. Industrial capital (or production capital). This is how the UK created an empire, we made things. we actually dug coal, built factories and manufactured stuff.

3. These others: Mercantile capital, Landlord and Rentier capital and Asset capital (selling titles to stocks for example) are not quite so dominant as finance capital in the UK. Although, Thomas Piketty has outlined the increasing role of rentier capitalism.

4. State capital. The government taxes then uses the taxes for things such as infrastructure to make more money.


So, capital takes various forms,  money needs to keep circulating in search of more money.  Capital has to flow or suffer losses, those who can speed up the flow will receive higher profits that those who cannot, innovation thus is very important. This flow also involves spatial movement, e.g. production processes have to be brought together with labour in particular spaces.

Once a capitalist has made a profit what stops them from just spending it all? Why do they keep the flow going?  The “coercive laws of competition” and the “social power” of capital acts to ensure capitalists move beyond consuming their profits and towards reinvesting. If I sit on my profit and just consume rather than reinvest then others who are in competition with me will innovate and steal my market and my profits will disappear. In addition, having even more profit buys me social power, I  can begin to ensure that I have a say in society in how this capital flows.

This reinvesting in the absence of barriers will produce compound growth of a certain %, depending on the circumstances and what is being invested in. For example, I invest £100 in a company and expect a return of  3% at least also depending on the rate of inflation. Any less than that then it may not be worth investing. If the return is 0% after a year and so I  get my £100 back, I will not be happy, especially if inflation means that £100 is now only worth £98.

Economists tend to agree that a healthy capitalist economy produces an average compound rate of growth of return of  3%, below this and we start to consider stagnant growth and recession. If that happens then capital lies idle and loses value. However, when we get returns of say at least 3% or more, this reinvesting leads to the “capital surplus absorption” problem. I keep making money but I need to reinvest it. Where are the new investments to come from? Where are the limits?

A crisis in capitalism occurs when ‘surplus production and reinvestment is blocked’. The barriers to investment have to be overcome.

There are 6 potential barriers to the flow of capital through production. Blockages at any one of these will disrupt the flow of capital and lead to a crisis of devaluation:

  1. Insufficient initial money capital in the first place. “I ain’t got no money”.
  2. Scarcities of, or political problems with, labour supply. “I got the money but I can’t find any workers”.
  3. Inadequate means of production – includes ‘natural limits’. “I got the money and a workforce but the tin has run out, the mine is barren”.
  4. Inappropriate technologies and organizational forms. “I got the money, the workers, the tin is there but I only have shovels and the market for tin only deals in gold bars, not money”.
  5. Resistance or inefficiencies in the labour process. “bugger, the workers want more pay”.
  6. Lack of demand backed by money to pay in the market. “I got the money, the mine, the men, the market but no one can afford to buy my tin”.

So the capital I owe lies idle and begins to lose value. I suffer a mini-crisis of my capitalism. if many sectors experience this, it becomes a major crisis.

The central dynamic of capital is thus the ‘capital surplus absorption problem’. What do we do with the surplus capital we have accumulated after bringing together the means of production and labour (in industrial capitalism) or after lending out money and earning interest (finance capital)? The coercive law of competition and social power means we will reinvest and keep the flow going. Crises are thus endemic because this dynamic will keep coming up against barriers and will need to transcend them through innovation, or ‘creative destruction’.

why study sociology in nursing?

The NMC (2004, 2010) has published standards for education programmes (Diplomas/Degrees in Nursing) and requires all student nurses to meet these standards and competencies during their education and before registering. This is one reason why you are studying the social context of care. If you read the standards you will understand why a wider knowledge of the context of care is required for nurses at the point of registration.

 Some students continue to struggle to see the relevance of sociology to their experience of nursing in clinical practice. The debate over sociology has been reflected in the literature especially in the late 1990’s but is still current. Does sociology have any relevance to nursing?’ The answer is partly based on what one thinks nursing practiceis.

 The case for sociology in nursing (Mulholland 1997):

1) It provides an alternative to individualistic biomedical models.

2) Supports critical and self reflective practice.

3) Addresses exercise of power.

4) Encourages a ‘quality of mind’ (Mills 1959).

5) Challenges the ‘taken for granted’.

6) Involves the ‘know why’ not just the ‘know how’.

One view is that nursing uses a science based biomedical model, is individually focussed involving concrete (evidence based) guidance for practical action. The knowledge needed for action is instrumental knowledge – knowledge for a purpose, ‘know how’.

The case against sociology in nursing:  (Sharp 1994, 1995):

1) Nursing is rational action directed to achieving measurable outcomes.

2) Nursing needs ‘know how’ not ‘know why’.

3) Nursing needs concrete knowledge based on certainty and unambiguous guidance for action.

4) Nursing is not about complex decision making and is thus non reflexive.

5) Sociology is multi paradigmatic and so cannot offer guidance for action.

6) Sociology is endlessly self reflective and questions all claims and assumptions and thus it is practically useless as it fails to meet the instrumental requirements of the nursing profession.

Another view is that nursing is complex decision making involving critical self reflection based on competing philosophies and theories. Nursing operates in power and social contexts, addressing populations as well as individuals. The knowledge needed is not just for action in practical settings (‘know how’) but for personal and social transformation (‘know why’).

Undergraduate students in practice may not engage much in analytical, critical, self reflective learning. They often describe what they see and read about. They learn task orientated, ‘correctly sequenced psycho-motor movements’ in an instrumental fashion to achieve essential skills and competencies. They often operate in a biomedically dominated frame of reference in chronic and acute illness and disease management with individual patients often in a hospital setting. They also often operate in a context where ‘getting the work done’ is paramount (Melia 1984). This work is often instrumental in nature: giving direct ‘hands on’ patient care. The emphasis is on the ‘doing’ not the ‘knowing’. The cultural view they bring into nursing is dominated by a hospital/medical frame of reference.


This makes sociology ‘difficult.’


Sociology encourages and requires transformational learning which does not sit easily within the current practical and power context of much of nursing practice. However, when students engage with the wider issues, and understand that there are different ways of knowing and examine what it means to develop a sociological imagination (Mills 1959), an opportunity exists for them to develop into ‘knowledgeable doers’ (UKCC 1986) who may transform both themselves, nursing practice and in turn society.


Melia, K. (1984) Student nurses’ construction of occupational socialisation   Sociology of Health and Illness6 (2) pp 132-151


Mulholland, J. (1997) The sociology in nursing debate. Journal of Advanced Nursing. 25 p 844-852.


Sharp, K. (1994) Sociology and the nursing curriculum: a note of caution. Journal of Advanced Nursing. 20 pp 391-395


Sharp, K. (1995) Sociology in nurse education: help or hindrance? Nursing Times. 91 (20) pp 34-35


UKCC (1986) Project 2000: A new preparation for practice. UKCC.  London


Wright Mills, C. (1959) The Sociological Imagination. Penguin. London 40th ed.

Intra-nursing issues and poor care?

Professer Jocelyn Lawler wrote a response to the blog below: I was interested in your take on this intriguing exchange about nursing and nurses’ place/role/future in what now passes for health care. I have been struck by the predominance of macro-sociolgical perspectives on nursing  and the extra-nursing location of the sources of the “problem”. What intra-nursing issues might we be brave enough to deconstruct? For example, I would point to a decline in collegiality among nurses in clinical settings, the reluctance to assist colleagues whose patients are in trouble etc. for fear of being implicated in some ugly outcomes and such like? Are you brave enough to get introspective about nursing’s own issues? I would be most interested in your thoughts.

Would I be brave enough? So I gave it a go!

Thank you for the reply. Introspective? Hard for a sociologically trained nurse like me! You make me reexamine my fundamental assumptions by asking that question. I don’t see a divide between macro (extra) sociological perspectives and the micro (intra). An individual’s ‘Agency’ and the social Structure are two aspects of the same coin, as Wright Mills suggests. Therefore to understand the personal troubles experienced by nurses and their patients we have to locate them within a particular period of (class and gendered) history and also examine the social structures that create the conditions within which agency occurs (and thus then ‘contructs’ agency by positioning social actors in a particular ‘subjectivity of experience’). We then follow through on how the exercise of agency then in turn reconstructs social structures if it can (perhaps in a new form). The relationship between the two is dialetical. Sociologically power is always present in this analysis, who has it, who exercises it and how it is manifest. Power acts upon agents (and gets agents to internalise power’s values) and in turn upholds certain socal structures until they are challenged. How hospitals manifest their power relationships at ward level is thus vital. 

Your point about ‘collegiality and reluctance to assist’ are agency actions performed within a particular hierarchical, managerialised, bureaucratised social structure at ward level. Collegiality may aso suffer due to the physical distancing and seperation of wards one from another.  Once the hospital team is broken up into small units that don’t communicate across clinical speciality you have a basis for a lack of collegiality. I am interested in how a key skill in the private sector is networking, especially for isolated professionals (viz the rise of sites such as LINkedIn). Networking in the private sector is seen as one way of achieving your goals, albeit in a competitive environment but networking allows individuals and teams to succeed. Without it they fall behind. But to what degree are nurses supported, trained, willing and able to do the same? This might be vital, as to engage in whistle blowing and collegiate support may rely on a sound social network not just within the hospital but across hospitals nationally and internationally. This current email network is a model for communication and cooperation and critique, I think it is invaluable.

Collegiality may also suffer due to the internalised view nurses have of themselves, that their experiences of subordinate positions (their ‘subject’ positions) first as women and then as nurses disempowers them. If nurses internalise cultural and social views about their place as women, the nature of their work and their ablity to affect change they may not be able  to challenge orthodoxy and a hegemonic view of their work.  I also thought of your work (which I am afraid to say does not get enough of a hearing as we have largely abandoned nursing theory in education) and the concept of bodywork which entails ‘dirty work’ and issues of disgust/intimacy and distance etc. At the micro sociological level, i.e. at ward level how nurses go about their daily work involves these conceptions about dirty work and for some disgust and distance is achieved not through the usual methods open to people but through a process of technical medico professionalisation which on the one hand provides much needed care but on the other validates disgust. Dirty work can then be left to assistants who are not sufficiently prepared, supervised or supported in carrying out bodywork.

It is not all doom and gloom, we are of course missing the voice of the empowered women leading health care in the direction of high quality, who of course have challenged their own subordinate subject positions to create and define new ways of working in nursing. Their agency is slowly changing structures as enlightened hospital management recognise their contributions (see Salford NHS Trust’s view of nursing as the ‘spine of the organisation’, the ‘go to’ profession as part of their saving lives campaign).

Intranursing perspectives? I really don’t know partly because the extra nursing issues and the intranursing issues are so intertwined that I struggle with seeing a difference conceptually between the two.

Thanks for poking me about this, maybe there is a need to write papers to explore these in more depth. A part of me dies at that thought, divorced as it is from the day to day bodywork and the subject positions that nurses experience as their reality each day. “the philosophers have sought to understand the world, the point is however to change it”

I am not sure I have answered you point. “Intra nursing issues” but just two thoughts:

1. An espoused theory of caring as valued role within nursing theory v the theory in action of distancing from ‘dirty body work (I need empirical evidence for that)
2. Status anxiety. Status is conferred by medical knowledge not nursing knowledge, climbing the medico-social ladder by acquiring medical skills is used to avoid status anxiety, i.e. a concern about how others perceive us if we engage in low status activities (body work).

I could go on but I might bore you.

‘basic nursing’

I was fortunate to be involved last night in a twitter chat on the subject of ‘basic’ care (#nurchat for you tweeters), this followed on from the recent Care Quality Commission’s report on Dignity and Nutrition which does not make pleasant reading. The issues are current and will be for a long time. I have to agree with Colin Holmes’ observation: “My theory is that these are deep-seated archetypes, established and maintained under the influence of powerful but subtle psychological and social forces, and although not completely impervious to change I don’t think that reiterating the facts of the matter will have much impact on them”.

The nursing archetype referred to is the ‘altruistic caring mother figure’ the implcation is that the graduate technically proficient nurse challenges this deep seated view. The archetype is founded upon gendered and class role perceptions and is addressed in the sociological literature (see for example Peter Morrall Sociology and Nursing 2001). Cognitive psychology teaches us about how we think, how we are prone to cognitive biases, Logic in philosophy teaches us the many logical fallacies we engage in when arguing and the advertising industry is accessing new and sophisticated means of persuasion (see George Monbiot on this “Sucking Out Our Brains Through Our Eyes” which bypass our critical reasoning skills. Thus the public understanding and public policy is not founded on clear and reasoned argument.

My perspective on this is that the “subtle psychological and social forces” will continue to work their ‘magic’ upon the public’s imagination because the public lacks the ‘sociological imagination’ required to excise the base gender/class archetypes. What is required is a Khunian paradigm shift within the public’s understanding of nursing, and this will only come about as the anomalies in thinking are constantly revealed in narrative and political action until a tipping point is reached.

This reinforcess my belief that resistance to the dumbing down of entry gates to graduate nursing and educational provision has to continue and that the nursing community must learn new ways of networking and communicating (social media such as twitter?) to build up the body of anomalies to challenge a hegemonic view of nursing practice. The anomalies include the research evidence of course, but this is much more than clearly communicating what we do and what nursing is based on: it requires stories, narratives, emotion etc, it requires political activism as well (I mean politics in the broadest sense).

Thanks to Peter Morrall I am reminded of Antonio Gramsci’s  ‘hegemonic dominance’ which relies on a “consented” coercion. Gramsci was of course analysing class relations in capitalist society in an attempt to understand why the working class accepted the values of the capitalist class as “common sense values for all”. Not until the cultural hegemony of these ‘common sense’ values are revealed for being merely class values, do we reach a a “crisis of authority” then the “masks of consent” slip away, revealing the fist of force.

In our context the public holds ‘common sense’ values about what nursing is, many nurses may hold onto those self same values, both groups not realising that these values locate nursing within a particular social construction of gendered and class understandings of work (e.g. nursing as emotional labour, ‘basic’ caring not requiring professional education etc) which are not common sense at all! Society does not value female labour in the same way as male labour, society does not value old age, why else do we shut them away in institutions that struggle to pay for enough expert staff to care for them? Western societies can find trillions to support an ailling financial system but public hospitals and care homes struggle to pay for enough skilled care in a classic Galbraithian ‘Private affluence-Public squalor’ allignment. That is a toxic mix allied to the archetypes Colin discusses.

So to address poor quality care:

1) value and pay for care – women’s care work is not ‘basic, it is not female work it is human work. 

2) value and pay for the elderly – the old have intrinsic worth not economic ‘value’. Capitalism must pay for all its members and not focus rewards on (often mythical)’wealth’ creators. 

3) develop staff, supervise staff, educate staff

4) sack or retrain failing staff

5) sack or retrain managers

6)….over to you.


Denial: Why do we deny what is put forward to us about climate change?denial


Denial:  Why do we deny what is put forward to us about climate change?


Climate change is utter fantasy that can neither be proved or denied. Imagination, not news. Sick to death of it”. 


This was a tweet received in response to a posting on the BMJ’s climate change conference. A good if sad example of denial. 


Scepticism is not to be confused with denial. Scepticism is the suspension of belief in order to subject a premise to rigorous questioning. Scepticism does not accept a premise without evidence or reason. Denial (like faith) ignores evidence, is frightened of evidence and looks the other way. Denial has its own agenda that prevents it from examining any evidence that contradicts it. 


Clive Hamilton (2010) suggests that the roots of denial in western countries (USA, UK etc) can be found in conservative politics, and specifically in the reaction to the fall of the Berlin wall in 1989 and the collapse of the Soviet Union. It has to be noted that climate scientists have been warning about changing temperatures before that date, however the implication of Hamilton’s thesis is that opposition to the science coalesces around this time. The argument here is that conservatives had been using a great deal of political energy into opposing the ‘red menace’, now that the Soviet block was no longer the threat, this energy goes elsewhere. Islamism is another channel for this political onslaught. In addition to these external threats for neo-conservatism (and its relation: neo-liberal economic theory) were the internal threats from lefty liberals: multiculturalism, feminism, anti-colonialism and environmentalism. 


The ‘green scare’ of the Rio Earth summit of 1992. 


There had previously been a history of environmental concerns before Rio. Aldo Leopold’s ‘Sand County Almanac’  (1949) and Rachel Carson’s ‘Silent Spring’ (1963) being two influential books during the twentieth century. However Rio, on the basis of the science, provoked a right wing reaction as it implicitly criticized core beliefs of the political right – the idea of human progress (based on nationalism, individual freedom and the ‘free market’) and the mastery of nature. Deep in the conservative (and also leftists’) heart lies an anthropocentric and dualist word view, that humanity is the centre of all things and that humanity is separate from nature not part of it. While the left accepts internationalism and internationalist governance, the right adheres more strongly to patriotism and nationalism which struggles with the idea of pan nationalistic governance which global warming implies is needed in some form. The free market ideology also requires hands off governance (unless of course it is to bail out banks).


Values determine belief.


Environmentalism challenges these core ideas and Rio, for the political right, in suggesting that international cooperation and treaties may be required to address the global issues, raised the spectre of (for them) ‘international socialism’. Even worse was that the science was casting doubt upon the idea that current growth economic orthodoxies always led to progress. Science as a central pillar of conservatism was being used to shake the core belief of progress. The cognitive dissonance thus set up has to be resolved – so there is a need to deny the science or reinterpret it as biased science produced by a liberal elite.


It is no coincidence that the current, most vocal, critics and deniers of climate science and environmentalism tend to come from right wing conservatism particularly in the anti science culture of bible belt America. 


However there are left wing critiques of environmentalism, arguing that is it a middle class smokescreen taking attention away from the class struggle against poverty and inequality.


Overlapping beliefs of both left and right include:


  1. Material consumption is a priority for human well being.
  2. A defence of human domination over nature.
  3. Anti authoritarian commitment to individual rights.


Finally the post modern turn in academia argues that there can not be objective truth, all knowledge including scientific knowledge is contingent and socially constructed, that science has no more basis for claiming its truth as any more valid than other non scientific world views. These understandings coalesce into climate denial. 


Another issue is that climate change may be a ‘wicked’ problem (Rittel and Weber 1974). It is complex in nature, with many solutions that may be possible but each one not able to solve it on its own. Wicked problems are thus difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems.


We are emotional creatures, we don’t make rational decisions based on hard evidence. A claim is that we have evolved to assess risk based on feelings rather than on cognitive processing (Hamilton 2010). Cognition takes training to apply to decision making. The science of cognitive psychology teaches us how bad we are at decision making, based on errors in thinking, this is supported by Jerome Groopman who argues that medical errors result more from errors in thinking than they do from technical incompetence. George Monbiot (2011) points out the power of advertising and the increasingly sophisticated ways the industry goes about its business, persuading us to buy stuff and manufacturing demand for often otherwise useless goods and services. The study of logic in philosophy also points out the many fallacies in thinking that we are prone to use. 



Therefore the reason why climate science does not drive policy is because human beings are involved in the decision making process and while we are ingenious in solving certain problems we seem incapable of solving others. The response to climate change science will vary from country to country depending on which values are being perceived to be threatened, because politicians and other policy makers react and act upon a myriad affective, cognitive, social and political influences and in democratic countries populations are not well placed to make those rational demands either through a lack of appreciation of the science, their emotional priorities or through the broken democratic political process itself. In addition, Pielke’s ‘iron law of climate policy’ applies, i.e when policy design to curb emissions comes up against economic policy, the economy wins every time: “it’s the economy stupid”.



And so we turn to maladaptive coping strategies.


Denial and its bastard children: hedonism, reinterpretation, blame shifting, false hope and hubris. 






Carson, R. (1963) Silent Spring. Haughton Mifflin


Leopold. A. (1949) A Sand County Almanac. OuP Oxford. 


Groopman, J. (2007) How Doctors think. Haughton Mifflin


Hamilton, C. (2010) Requiem for a Species. Earthscan. London.


Monbiot, G. (2011) Sucking out our brains through our eyes.


Pielke, R. (2010) The Climate Fix. What Scientists and Politicians won’t tell you about climate science. Basic books. New York  


Rittell,H. and Weber, M. (1973) Dilemmas in a General Theory of Planning, pp. 155–169, Policy Sciences, Vol. 4, Elsevier Scientific Publishing Company, Inc., Amsterdam,  [Reprinted in N. Cross (ed.), Developments in Design Methodology, J. Wiley & Sons, Chichester, 1984, pp. 135–144.],


Communicating health messages in contemporary culture.

Jon Snow, the channel 4 journalist, chaired the morning’s panel discussions at the BMJ’s ‘Climate Change, health and security’ conference held at the BMA in London on Monday 17th October. In addition to his skills and experience based on years of writing and presenting, he brought interesting insights into how the media works, insights which healthcare professionals could learn from.

One message was that the media had lost interest in climate change, partly due to the hard lobbying by climate sceptics, partly due the East Anglia ‘climategate’ emails but also due to the financial crash of 2008. This illustrates Roger Pielke’s ‘iron law of climate policy’: “when policies to curb emissions come up against policies for economic growth, economic growth wins every time”. The lesson? Messages compete on an ideological stage for their performance time.

The medium of communication is important. The panel of 9 on the stage were asked whether they use twitter. One person affirmed this to be the case. Snow pointed out that those working in the media use twitter and other social networks as core tools in their armoury. Snow argued that he gets a great deal of useful information from twitter and suggested that the doctors ought to seriously consider it as a medium of communication.

This illustrates another issue. Healthcare professionals work in a particular communication bubble, as do academics. Those who we need to communicate with (the public, journalists) live in another communication bubble. There is some crossover between the two but the implication is that healthcare professionals (clinicians and academics) are out of the communication loop, that the overlap between the two worlds is not large enough.

At root is a misunderstanding of the link between knowledge and policy decisions/public understanding. Healthcare knowledge is often  science based and rooted in medical understanding. There were suggestions from the floor that the science needs to be simplified and clarified in order to transmit the correct messages. This will not work in the way we think it ought to.

Firstly, policy and understanding is not based on medicine and science, it is based on what the popular culture tells us, which in turn is shaped by various vested interests, ideology, misconceptions, advertising, public relations and dominant cultural paradigms (e.g. the ‘economic growth’ paradigm, the tenets of consumer capitalism, anthropocentrism and philosophical ‘dualism’ i.e. the ‘objective-subjective’ , ‘nature-man’ divide).

Secondly we are using the wrong tools. Those who need the messages do not attend conferences, read academic journals or are linked into professional networks. They use facebook, twitter, radio, television and popular magazines. These media are not often used enough by academics, doctors and nurses.

Therefore the worlds are apart, divided by the understanding how the world works and by different tools of communication. The growing interest in ehealth and web based methods is an attempt to bridge that divide, but to date is still in its infancy. This is not to say these attempts are entirely absent, see for example the facebook group ‘Nursing Sustainability and Climate Change’, or the ‘Climate and Health Council’ website, but that there is a long way to go to understand what our story is and how to best connect with a wider audience. Healthcare professionals need to learn from media studies, social marketing and cognitive psychology on how to reach those who matter if we are interested in promulgating our messages.


Pielke, R. (2010) The Climate Fix. Basic Books. New York.

Nursing Sustainability and Climate Change

Climate and Health Council

‘Ego or Eco’ and human health

Sustainability and Health This paper seeks to discuss the concept of sustainability and its relationship to health. It will argue that an understanding of what ‘health’ is needs to change from an individualistic (egocentric), biomedical definition to one that encompasses a more social-environmental (ecocentric) understanding. An individualistic (egocentric) understanding of health decouples the individual from society and the ecosphere and this decoupling results in inadequate preparation of some health professionals to equip them to deal with global health challenges. Sustainability, with its emphasis on the ecosphere, recouples the individual to the environment. This matters because the challenges to human health on whole population levels require a paradigm shift to enable adaptation and resilience to changing environmental circumstances (Selby 2007). Before defining sustainability there is a need to briefly address three related concepts: ecocentrism, egocentrism and the ecosphere. Ecocentrism is based on valuing ‘nature’ (or the ecosphere), and places humanity as subservient rather than as dominating and in control. Egocentrism is a system of values that puts the individual human at the centre of ethical discourse, there is a tendency to ignore society and the ecosphere. The ecosphere refers to the air (atmosphere), the oceans (hydrosphere), the land (geosphere) and all life forms (biosphere). ‘Sustainability’ as a concept is not new. Schumacher (1973) had argued that current (modernist) economic models resulted in inefficiencies and environmental pollution while the earth’s finite natural capital resources were being used without too much thought for the future. The recent increased global concern with climate change/global warming (IPCC 2007, DEFRA 2008) has brought it back into the spotlight for the general population. A problem is an egocentric paradigm which values the needs of humanity over the ecosphere. Sustainability can be defined as the ‘capacity to endure’. It is ‘the potential for long-term improvements in (human) wellbeing, which in turn depend on the wellbeing of the natural world and the responsible use of natural resources’ (definition from Wikipedia). Although this seems straightforward O’Riorden (1985) commented on the difficulty of defining sustainability, describing its definition as an: ‘Exploration into a tangled conceptual jungle where watchful eyes lurk at every bend’. Spedding (1996) argued that there is a ‘ remarkable number of books, chapters and papers, that…use ‘sustainable’ or ‘sustainability’ in the title but do not define either term. Spedding goes on to argue, in an attempt to explain sustainability, that it must be based on: 1) resources that will not be exhausted, and 2) it must not create unacceptable pollution.  One of the most oft quoted definitions and one to which we will return below is: ‘Sustainable development: ‘is development that meets the needs of the present without compromising the needs of future generations to meet their own needs.’ (WCED 1987). However, both definitions do not challenge the ‘right’ of humanity (as a separate dominant entity) to extract and exploit nature, only to do it without causing long term harm. There is therefore a great deal of thinking and discussion to be had in trying to understand and clearly communicate exactly what we mean by the term. However, we may argue that human health and wellbeing is self evidently connected to the continuance of the ecosphere as a hospitable environment and in accepting this connection we must value the ecosphere (ecocentrism). It could therefore be argued that a health care worker will be (should be?) as concerned with the socio-political and environmental issues as much as that of curing and treating individual illness. Those that work in public health, health education and health promotion may have more of an explicit concern for these concepts in their professional lives, but the fate of the ecosphere does not exclude or favour anybody. Individuals may be exhorted to change their behaviour but in the absence of environmental protection, this may be totally ineffectual in the long run for humanity. Individuals may still prosper but the species may not. There is a suggestion of a global environmental (Hamilton 2010) and health (Costello et al 2009) crisis. Despite global warming deniers (Philips 2007, The Great Global Warming Swindle 2007), the Intergovernmental Panel on Climate Change (IPCC 2007) report makes it clear (and based on conservative estimates) what our challenge is. If the global community does business as usual, the future may be bleak for humanity. Even if global warming turns out to be exaggerated and the deniers proved correct, the alleged depletion and despoiling of the environment would render the discussions around the best way to deliver health irrelevant. In ‘Climates and Change’ the UK Public Health Association (UKPHA 2007) argues that issues such as pesticide use, ozone depletion, acid rain and Cheronbyl have all highlighted the threat to the ecosphere. Sinclair’s (2009) contention that this is so, is based on reports such as the UN Conference on Environment and Development (1992), the IPCC (2007) report, the Royal Commission on Environmental Pollution and the World Wide Fund for Nature’s (2007) report (all quoted in the UKPHA’s report). If we assume the crisis to human health (if not our continuing existence) is very real, it could therefore be argued that healthcare workers need to address concepts that are otherwise alien to them. Sustainability and Global warming may not have been normally seen as health issues, but less than moment’s reflection surely establishes that they are. Further, the Department of Health (2008a, 2008b), the UKPHA (2007), International Council of Nursing (2008), British Medical Association (2008, 2011) and the World Health Organisation (2006) all have highlighted this as an issue. Therefore returning to asking the question: ‘what does sustainability mean (and what may be the links to health?)’, Fiona Sinclair and David Hall present two perspectives (among many). The Brundtland Report (WCED 1987) may have put the global economic system largely unchanged at the heart of its understanding but this approach may be seen as no more than ‘greening the consumer machine’. Sinclair is arguing for a far more radical approach. Hall, however argues that business is addressing green issues without the need to radically alter lifestyles. In ‘What is Sustainability’ Fiona Sinclair argues: ?‘Sustainability is…not earth shoes, organic eggs, hybrid cars, carbon credits, hemp clothing, a green Apple Mac book™, consumer co-ops, E85, B20, compact fluorescents, recycling bins or reusable shopping bags. All these by products of the consumer lifestyle are predicated on the natural world supplying resources. Capitalism goes shopping in the cavernous belly of mother earth seemingly blind to the fact that the store is running out.’ Thus, Sinclair points to a consumerist lifestyle at the heart of the matter and further argues that the Brundtland report is fundamentally flawed: ‘the Brundtland Report… set(s)……a precedent which links sustainability…(with) the global marketplace. As a result economics has become one of the pillars with which to define sustainable outcomes’ Brundtland, she argues, supports the idea of the People/Profit/Ecosphere triad: ? …whereby the assumptions of global markets as a foundation for human development and sustainability are not shaken. The quest which flows from this analysis is to ensure that the markets operate to provide a sustainable future. Consumerism is to become green. Sinclair argues that profit should be replaced by a global consciousness that accepts that we are interconnected, that environmental degradation is a very real and present danger to continued existence (ecocentrism). The markets in this scenario cannot provide the answer as their primary purpose is for profit and the continued exploitation of a dwindling resource. ? ‘Global consciousness enables us to see effects right in our own backyards and therefore make decisions that instigate solutions with immediate results. It’s that local/global thing granted, but it really is very important that we get it, because if we can’t see our own complicity in all the global destruction that’s going on when it’s right in our faces, we will never understand the consequences of our actions further afield. We will never understand how that early morning cup of coffee unites us with a farmer in Ecuador unless we map the route back to ourselves’. David Hall (2007) takes a different tack to say the least. He argues ‘In slashing the price of lightbulbs, we have shown how green consumerism can work’. Hall starts by quoting his challengers Mark Lynas (2007) and George Monbiot (2007): ‘Lynas argues that, as high-street chains rush to go green, the message to customers is that “all you have to do to save the ecosphere is shop”. This “green consumerism” is dangerous, he says, as it is “difficult to see how consuming more of anything can help us save the ecosphere … The point is to consume less – and no one’s going to make any money from that.” Covering an impressive range of issues, from advertising to carbon labelling, supermarkets and offsetting, Lynas quotes George Monbiot’s memorable put-down, “No political challenge can be met by shopping”, before coming to the depressing conclusion that “clearly a lot more work remains to be done”’. However he goes on to state: “By caricaturing this business response as “more shopping”, however, much positive work is misrepresented. When it joined our campaign, Tesco made a commitment to sell 10 million energy-efficient light bulbs this year (up from 2 million last year), and has slashed prices and transformed its range in order to do so. How can that be a bad thing when a single low-energy bulb saves on average 11kg of CO2 and £8 in energy bills per year? We cannot afford to stick to old divides. If defeating global warming requires us to defeat global capital too, I would suggest we all give up now and start building our arks. But if we can harness the power of a Tesco or an M&S to our cause, we may just have a chance of keeping our heads above water.” Thus, far from being the cause of the problems the global consumer is to be aided in preserving and sustaining the ecosphere by corporations. ‘Sustainable Health’ has another face. An expression of sustainable health may be seen in the flight from medicine towards alternative and complementary therapies. ‘Sustainable Health’ (a UK) based organisation (see uses ‘sustainable’ as a ‘hooray’ word (who is against sustainability?) to attract customers to use their products and services. Their website makes it clear what sustainability means: ‘We offer treatments in Acupuncture, Ear Acupuncture Aromatherapy, Raindrop therapy, Reiki, Herbal medicine, Indian head massage, Counselling, Shiatsu, Sound healing, Crystal healing, Breath work, Reflexology, Astrology, Self Development, Qi Gong, Meditation and Native American medicine’. Not all of these therapies have an evidence base of course, but other than that they also conceptualise health from an egocentric perspective. It may be a harsh criticism to note that the social-political and environmental dimensions are missing as these therapies are not about that. What it does illustrate is that sustainability can ‘mean all things to all (wo)men’ and can be used to rally the troops. Implications for health care. From an egocentric perspective, an individual’s health is not connected directly to other’s or the ecosphere. One person’s health may be in an optimal state regardless of the environment, therefore at the locus of the individual health can be decoupled from the environment. From an ecocentric view, the environment is coupled to the individual, they are seen as one and the same, then individuals cannot be healthy by definition if the environment is despoiled. Sinclair’s approach to sustainability would have us make the connections between our personal lifestyle choices and the impact this has on global resources, re-coupling the individual and the environment. Therefore it moves the focus on from health and healthcare based around treating individual illness and disease (biomedical egocentrism). It is a call to understand health in its widest dimensions, that individual health is inextricably linked to individual, social, political and economic and environmental decisions which accepts that the ‘State of the World’ is as important as an individual’s health (ecocentrism). The ecosphere does not need us, but we most certainly need the ecosphere. Sinclair does not explicitly argue that rejecting a consumerist lifestyle is as healthy for individuals as it is for the ecosphere but implicit in this approach may be the assumption that less than optimum health for people may actually be beneficial for the ecosphere. How may this be? On the plus side, selling one’s car and using a bicycle will have benefits (all other factors being equal) for both ecosphere and the individual. However, rejecting the products of the pharmaceutical industry and relying on ‘traditional’ herbal remedies may have serious negative health consequences for the individual. The ecosphere benefits from having less non renewable resources being used, but the individual may find life expectancy reduced. How much of our current lifestyles based on the production of goods and services need to be sacrificed before we experience a health threat? It has to be noted (McKeown 1976) that increases in life expectancy in the developed world has resulted from the benefits of a rise of general standards of living, environmental improvements and nutrition facilitated by the global markets (Ben-Ami 2010) that are criticised. We are healthier in the main than our great grandparents. The issue is whether this increase in life expectancy has been bought at the expense of the environment. The question remains whether global capitalism can continue to produce health gains for a world population of nearly 9 billion? Schumacher (1973) argued 20 years ago that it cannot. Sinclair, and many others (Orr 2004, Jackson 2009, Porritt 2009, Hamilton 2010) agree. There may be alternatives, Cuba’s health care system shows what can be achieved without applying market capitalism (Carrol 2007). However this is based on certain philosophical and political assumptions that are difficult to export. Global and environmental consciousness (ecocentrism) may be an ideal, an ideology to be achieved in some utopian future, so there is a need to show evidence that 7 billion people currently are interested in anything other than development along consumerist lines. Pielke (2010) argues that there is an iron law of climate policy: when economics comes up against emissions reductions then economics wins. This may apply to changing to sustainable lifestyles as people will not respond if the cost is too much. In ex US president Bill Clintons’s words “Its the economy stupid.” Getting individuals in western societies to change consumption habits to protect the environment may be difficult enough, it may prove an impossible challenge to persuade China and India that the path to development involves less not more (Pielke 2010), especially as the ‘brand leader’ of consumer capitalism, i.e. the USA, seems unwilling to do other than to green its products while ignoring gross inequalities which has huge impacts on a range of health and social problems (Wilkinson and Pickett 2009). Hall’s response is that business is attuned to offset the more damaging effects of its activities. The World Business Council for Sustainable Development (WBCSD 2010) agrees. Both suggest that current healthy (longer) lives can be sustained if we make adjustments to lifestyle and consumer choices rather than undertake a radical overhaul of the whole economic system. There are of course objections to this model (NEF 2010. Jackson 2009, Hamilton 2010). Those who wish for ‘business as usual’ are putting their faith in human exceptualism (and are egocentric) and technological fixes (Ben-Ami 2010) and may be downplaying the real toll of current consumer demand in terms of environmental degradation. Affluence for billions (while other billions live on less than $10 a day) and faith in technology masks very real problems. The challenge is to develop an individual and environmentally healthy lifestyle that does not draw upon more resources than can be renewed, but which harnesses the benefits of development to prevent a new dark age from descending. The decoupling of individual health from the environment makes this challenge more difficult. Healthcare professionals need to reconnect and advocate for a changed paradigm and for lifestyles that are sustainable and healthy. Benny Goodman. November 2010.

A doctor writes on climate change, I respond.

Climate change and human health?


This was posted by on the doc2doc website (   by skyesteve  in response to the BMJ’s Climate change conference on 17th October 2011: I responsed in red below.

In November 2010 I saw something in the medical literature that I had never seen before. An editorial was published simultaneously in the British Medical Journal and The Lancet (1), (2). It was written by Ian Roberts, Professor of epidemiology and public health at the London School of Hygiene and Tropical Medicine and Robin Stott, Co-chair of Climate and Health Group and it sought to address the issue of climate change from the perspective of its impact on the medical profession and our role in addressing the issue.  In doing so Roberts and Stott attempted to use what were, effectively, news headlines to try and demonstrate some “cause-and-effect” proof of climate change. I felt that this was a risky strategy as such headlines seldom allude to the multi-factorial nature of the underlying stories. As a consequence, when these headlines are dissected and the underlying complexity is revealed, there is the very real prospect that the argument that you wish to present becomes diminished and devalued, perhaps to the extent that the very people you most need to convince choose instead to ignore your point of view.

Roberts and Stott used three such headlines from 2010 as their opening gambit – the devastating floods in Pakistan; the wildfires in Russia; and the food riots in Mozambique. So how do these stories stand up to dissection? Are they, as Roberts and Stott might claim, mainly “climatic events…the main cause of which is the increase in anthropogenic greenhouse gas emissions”? 

The floods earlier this year in Pakistan were, without doubt, catastrophic in their impact. But were these floods and their devastating consequences simply the result of climate change?
 The Indus is a vast river which, according to the geological evidence, has been prone to flooding for millenia. Over 6000 years ago the river was actually more voluminous and more prone to flooding than it is today. Millions of people now make their homes on the flood plain of the Indus and, consequently, as this population has increased so too has the impact of any flooding that occurs. The population of what we now refer to as Pakistan has increased from 34 million in 1951 to over 170 million today. It’s hardly surprising therefore that, in terms of the number of people affected, any current natural disaster is going to have an impact of historical proportions. As highlighted by Scientific American (3), the causes and consequences of these floods are not simply down to climate change – there is “evidence that points to a calamity caused by man, the cumulative effect of erratic weather, forecast by climate change models; massive deforestation; and lax attention to infrastructure maintenance and engineering standards”. In particular, a western-style levee system that does not seem to cope well with the silt-laden floods waters of the Indus, causing the river channels to silt up. This is fine so long as the levees hold but when they break the consequence can be far more devastating. In addition, mass deforestation has taken place in Pakistan which makes catastrophic flash floods much more likely.  

So what of the wild fires in Russia? Certainly they were (as with the Pakistan floods), at least in part, the result of climatic conditions. Russia had its warmest summer since records began – but they only began in 1890. A record temperature of 44C was reached – but this was only 0.2C higher than the previous record set in 1940. The wildfires were not simply the result of extremely high temperatures. Again, other man-made factors may also have been at play.  Russia has approximately 25% of the world’s forests. Wildfires are a natural consequence of such arboreal landscapes and existing Russian forests contain evidence of fires going back hundreds of years. Despite this the vast majority of forest fires in modern Russia are down to deliberate fire-raising or wilful neglect of things such as agricultural burning.  Catastrophic wildfires in Russia are nothing new. In 1915, a particularly dry year, 12.5 million hectares of Russian forest was destroyed by fire whilst in 1921, wildfires in the Mari region extended to over 2600 square kilometres. During the 1950s soviet authorities displaced thousands of people to remote forest areas to exploit the local natural resources. This too resulted in the burning (deliberate or otherwise) of tens of millions of hectares of forest.  During the 1960s Russia’s extensive peat lands were drained drying out the peat and making it much more susceptible to persisting (and difficult to deal with) deep, underground fires. Major fires erupted in 2002 causing widespread damage and pollution.  The 2010 wildfires destroyed over 1 million hectares of forest in western Russia. But there were 1.3 million hectares destroyed in 2002, 2.3 million hectares in 1998 and 2.4 million hectares in 2003. In other words, such catastrophic losses are not that unusual in Russia (4).

Finally we come to Mozambique’s food riots. Once again Roberts and Stott seem happy to use them as evidence of the consequences of climate change but is that the full picture?  The riots in Mozambique were brought about when the government of that country decided to raise wheat prices in response to rising world prices and in the face of what they regarded as unsustainable subsidies (they later recanted that decision). Mozambique grows only 30% of the wheat it needs and is therefore heavily dependent on imports. Yet reports suggest nearly 90% of the potential agricultural land in Mozambique remains poorly cultivated or even uncultivated due to a combination of factors including poor infrastructure and a lack of sufficient investment.  The cost of wheat did go up in 2010. At least in part this was the consequence of flame-ravaged Russia halting exports (Russia accounts for 8 to 10% of the world’s wheat production). In addition, the switching of agricultural land elsewhere to other activities such as bio-fuels production has helped to fuel a perception of shortage. Yet in reality the world is not short of wheat. As pointed out by the BBC (5) there is no shortage of agricultural land in the world as a whole and higher wheat prices may actually boost production (which has already risen by 10% in the last 4 years). Production in 2009-10 was about 5% higher than consumption and significant reserves of wheat existed. Indeed, the price of wheat at the time of the Mozambique riots was 40% less than it was at its peak in 2008. In addition, the increased cost of imported wheat for Mozambique was due in no small part to the loss of value of the Mozambique currency against the South African rand. 


I now want to address some of the concerns Roberts and Stott raised around climate change and disease as this clearly has potential impacts on us as doctors. Do the worries they express stand up to scrutiny and, if climate change is playing a role, is that what we should be really worried about when it comes to public health and disease? 

I will leave aside their justified remarks about the obesity epidemic in Mexico where, I would suggest, the approximately 30,000 deaths from homicide in 2010 is probably the most pressing current public health issue.
Instead I would like to look at the 5 health areas they highlight – malnutrition, diarrhoea, deaths from floods, malaria and temperature-related deaths from cardio-vascular disease. I have already alluded to the issue of flooding but what of the other four areas that they highlight?  

Malaria has been with us since the dawn of human history. It has been recorded in China as far back as 2700 BCE and a study of Egyptian mummies from the time of the New Kingdom (1550 – 1069 BCE) has found that they were universally infected with malaria. Some historians have even suggested that malaria may have contributed significantly to the fall of the Roman Empire.  The so-called Little Ice Age in Europe lasted from the 16th to the 19th centuries with particularly cold dips around 1650, 1770 and 1850. Yet throughout that time malaria was endemic in much of Europe and the USA. It was still present as far north as the Arctic Circle as late as 1950. In the 1880s over 5000 labourers died from malaria whilst working on the Panama Canal. At this time malaria was still endemic in the USA, England, Italy, Holland, Russia and elsewhere in Europe. In 1918 in Italy there were 2 million cases per annum. In 1924 Soviet authorities admitted to 5.5 million cases annually in Russia (and the real figure was perhaps twice as high). 

In all these areas malaria was tackled successfully by simple measures – treating or draining breeding grounds (marshes and swamps) and using insecticides and anti-malarial drugs. By 1945 malaria had effectively been eliminated form the USA and most of Europe. But the worldwide incidence was still 300 million cases per annum.  

But eradication and therapeutic measures were also used effectively in other parts of the world. This had a dramatic initial impact. India, for example, saw the number of cases reduced to about 100,000 by 1961. Sadly the good news was relatively short-lived. Resistance to (and, in the case of DDT, withdrawal of) pesticides and drugs has seen malaria fight back. By 1977 cases in India were up to 6 million a year and between the 1960s and 1990s the global number of cases of malaria has increased 3 fold.

In 2008 WHO estimated 247 million cases worldwide of which 1 million died. (6) But all these statistics have to be seen in context. In 1945 there were an estimated 300 million cases – but the world’s population was only 2.1 billion. In 2008 there were 247 million cases – but the world’s population had almost tripled to 6.1 billion. So the incidence of malaria in 1945 was around 13% of the world’s population – by 2008 it had fallen to 4%. Even if the worst-case scenario is realised – a doubling of current cases of malaria by 2050 due to climate change – this will be against a rise in the total world population to over 9 billion people such that the incidence will still only be 6.6% – half of what it was in 1945. 

I am not trying to downplay the serious impact of malaria. One million deaths is no laughing matter and nor is the undoubted negative economic impact of malaria on the developing world. But I do dispute that climate change is the main issue here. It’s not. The main issue is the need to invest in simple measures which have been shown to be effective time and again – improving health care generally; tackling the breeding areas; using physical and chemical barriers (e.g. net impregnated with pesticide); and judiciously using drug therapy (and, hopefully, the development of new therapies). WHO estimates that for an investment of just US$1 billion they could half the number of cases of malaria – that’s the same amount of money that Pfizer made from the sales of Viagra in 1999 (7).  

Now what of thermal deaths? WHO suggested in 2003 that the rise in global temperatures between 1970 and 2000 had resulted in an additional 130,000 heat-related deaths – I will come back to that shortly.
In 2001 the UK Climate Impact Programme looked at thermal-related deaths (8). They projected into the future to look at deaths in 2080 based on a worst-case scenario of a 3.47 degrees Celsius temperature rise from the 1960s baseline. They estimated that such a temperature rise would result in the number of heat-related deaths in the UK rising from just 798 in the 1990s to 3519 by 2080 – but, at the same time, the number of cold-related deaths would fall from 80,300 in the 1990s to 51,200 in 2080 such that the overall number of lives saved in the UK from prospected global warming would be around 28,000 per annum by 2080! Similar pictures are likely to be seen in other temperate climates. In hotter climates where cold-related deaths are seldom an issue such a trade off will not exist and heat-related deaths may rise (though presumably people will adapt to hotter climates to some extent).

If we return to the WHO figure of an extra 130,000 heat related deaths between 1970 and 2000 how does that stand in relation to the number of cold-related deaths? Well, looking at the WHO figures it seems that whilst there were 130,000 more heat-related deaths there were perhaps as many as 620,000 avoided cold deaths meaning a total number of lives saved of 490,000 (10). Similar analysis can also be made of the other three areas that Roberts and Stott highlight as health-related impacts of climate change. 

At present there are an estimated 950 million malnourished people in the world despite the fact that the world already produces enough food to feed its 6 billion residents. Climate change may have a role in terms of food security but it is not the major concerns. Almost every country with malnutrition problems is crippled by poverty, corruption, and violence. Couple this with a lack of investment in infrastructure and agricultural developments and it’s not hard to see what the real cause of malnutrition is. But the reality overall is that, according to the United Nations,  global malnutrition rates fell between 1970 and 2010 (despite rising global temperatures) from 37% of the developing world’s population in 1970 to 16% in 2010 (11).  

And what of diarrhoea – is climate change the main culprit here? Not according to a WHO news release from 2009 (10) which states that: Inexpensive and effective treatments for diarrhoea exist, but in developing countries only 39 per cent of children with diarrhoea receive the recommended treatment…despite the known benefits of improving water supply and sanitation, some 88 per cent of diarrhoeal diseases worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene. As of 2006, an estimated 2.5 billion people were not using improved sanitation facilities, and nearly 1 in every 4 people in developing countries was practicing open defecation. 

Perhaps before using diarrhoea as an example of the horrors of climate change we should tackle the basic problems and cheap solutions first. 
 (agree).I feel that the whole climate change debate has become increasingly sterile and it seems to be caught in a perpetual loop of claim and counter-claim. No-one seems to baulk from the idea that the planet may be warming but they argue about how much warming there will be (but the range is not disputed) and what will be the impact on mankind  (the exact nature of the impact has much room for debate but there is agreement that  it will significantly impact)and how much are anthropogenic greenhouse gases to blame (there is very broad agreement among scientists that CO2e’s are too blame), and so on.

 I am not trying to down play the importance of climate change – I think that it is happening and I think that it may be, at least in part, anthropomorphic in origin. I am also open-minded about what the possible consequences of this change might be for us as doctors. But I am concerned that the inappropriate use of “headline stories” can reduce the impact of the argument and actually works against that which we are trying to achieve. (Agree, this is about how we communicate not what the message actually is)

It seems to me that everyone is ignoring the two
(three)big “elephants” in the room – population growth and dwindling natural resources related to the sustainability agenda, and neoliberal capitalism.The world’s population is far too big – we currently have over 6 billion people on a planet that perhaps is only geared to cope with about a third of that number. And this population pressure is often worst in those regions that are least equipped to cope with it. Yet little is being done on a global scale to tackle this issue.  It’s also a “no-brainer” that most of our essential natural resources are finite in nature and that we need to plan ahead for a world without them. Oil is the obvious example yet, despite only an estimated 30 or 40 years of oil remaining there is no concerted world effort to plan for a future without oil. We need to take drastic measures now to reduce our consumption of resources but again we see almost nothing happening.  Until and unless we are prepared to tackle the issues of population and resources then there seems to be little point in arguing about the finer nuances of climate change.


Thank you for a considered well argued and thoughtful piece. I cannot disagree with many of your points. However, climate change and carbon reduction are still immediate issues along with your population growth and resource use points. They are all linked.


I agree that the three flood, fires ad food riot events are mutlifactoral and are not evidence of climate change. They merely illustrate how increasing temperatures may interact with the social, political, historical and environmental factors that currently exist. The complex nature of climate change is such that we can only suggest ways in which this extra factor (rise in global mean temperatures) will impact on such pre existing factors in the future, pointing out that it may be a either a tipping point factor in among many, or that it may introduce such a dramatic change that the ecosystems that support health collapses relatively suddenly. The claim (if made) that these events are a result of climate change is therefore nor helpful. However they may illustrate the type of event that could in future be a result of global mean temperatures rise.


The issues outlined (malaria etc) are occurring in the current temperature range and are affected by various factors and many have solutions that could be put in place reasonably easily. Climate change has little to do with them right now. The argument is that when we reach global mean temperatures of over 2 degrees or up to 4 or more, then the ecosystem feedback loops that kick in (12, 13) will have potentially devastating health impacts. It is accepted that the current 387 ppm (14)  of CO2 in the atmosphere (2008 figure)  is linked to the rise in temperatures and that even if we reduced carbon emissions to zero today, the ppm will continue to rise for many, many years (the lag effect of CO2). Therefore climate change should concern us now not because the events you describe are results of climate change but because in the future human populations may experience rapid changes in their ecosystems that they may have extreme difficulties dealing with.


You argue “Perhaps before using diarrhoea as an example of the horrors of climate change we should tackle the basic problems and cheap solutions first.  (I agree). I feel that the whole climate change debate has become increasingly sterile and it seems to be caught in a perpetual loop of claim and counter-claim (often though due to the ill informed and vested interested oil lobby). No-one seems to baulk from the idea that the planet may be warming but they argue about how much warming there will be (but the range is not disputed) and what will be the impact on mankind  (the exact nature of the impact has much room for debate but there is agreement that it will significantly impact) and how much are anthropogenic greenhouse gases to blame (but there is very broad agreement among scientists that CO2e’s are too blame), and so on”.


The measures that will reduce emissions produce co benefits now.  In addition, your emphasis on population  growth is a key issue linked to development (populations stabilise  as they get affluent), but the natural resource issue is equally important and will be harder to crack in the context of current economic orthodoxy (neoliberal and other forms of capitalism) that requires growth. I agree, we need to take drastic action now to curb population growth as soon as possible and to restructure our economies to address resource use, that way we will also address carbon emissions. The transition town movement is one such attempt, it may not be enough. The BMJ conference focused on climate change, but there is the need to link sustainability and political economy to understand the whole picture. Anyone who uses only the current health impacts of climate events as an argument has partial view.





1. Roberts, I. Stott, R. Doctors and Climate Change, BMJ 2010; 341:c6357

2. Roberts, I. Stott, R. Doctors and Climate Change, Lancet 2010; 376: 1801 – 1802


3. Gronewold, N. Scientific American (on-line) October 12, 2010

4. Taiga Rescue Network: Fires in the Russian Taiga: Natural Disaster or Poor Management? December 2004


5. BBC News (on-line) September 3, 2010


6. World Health Organisation Media Centre Fact Sheet Number 94 Malaria: New York: April 2010 


7. World Watch Magazine May/June 2000


8. Department of Health Expert Group on Climate Change and Health in the UK: Health Effects of Climate Change in the UK: London: April 2001


9. Lomborg, B. Cool It: The Skeptical Environmentalist’s Guide To Global Warming, P.126 – 127. London: Marshall Cavandish Ltd 2007 (ISBN 978-0-462-09912-5)

10. Food and Agriculture Organisation of the United Nations: The State of Food Insecurity in the World, Italy: 2008

11. World Health Organisation Media Centre News Release: Reducing Childhood Deaths from Diarrhoea; New York: October 14 2009

12. Lynas, M. (2007) Six degrees. Our future on a hotter planet. Fourth Estate.

13. Hamilton, C. (2010) Requiem for a species. Earthscan. London.

14. ‘World CO2 levels at record high warn scientists’





what is our story now that the story of neoliberalism triumphs?

The BMA conference on ‘climate change, health and security’ was not much fun. There is a good deal of anxiety provoking news from those who are monitoring the planet’s health. Senior military personnel, scientists, doctors and industry representatives (Lloyds Insurance, Marks and Spencer) discussed the need to act to reduce carbon emissions and to plan for a very difficult future. Actually, to call it a ‘difficult’ future is like referring to Hitler as a bit ‘difficult’, it is Jeevesian understatement of immense proportions.


Talk of climate change creates denial because it is anxiety provoking. Denial deals with anxiety by taking away the source of the fear. Denying the obvious is not rational but we are not rational decision makers. There is also a vested interest lobby(ies) promulgating lies, deceits and half truths.  Some deniers are sincere in their dismissal, science itself is complex and cannot deal in certainty. The actions of some scientists themselves have given unintended succour to the denial camp.


Thus we are faced with a huge task, getting the public on board with the seriousness of the global threat to health and security that climate change entails. The deniers are better organised, better funded and keep to simple messages: the science is unclear so why rush into something we know little of, the earth is warming but it is not our doing, we have the technology so we can fix this.


Rosabeth Moss Kanter (2009) suggests 4 ways to deal with denial:


1.    Unassailable facts. Make sure the evidence is beyond reproach.

2.    Counter-arguments. Answer each one and know their arguments, respond, confront and accept grains of truth.

3.    Big Picture (or ‘Vision’). Change rests on beliefs not just facts, identify the long term benefits.

4.    Pressure and repetition. Keep pressure on the deniers, stay on message and keep communication going.  


I wish to deal with the Big Picture, a ‘vision’. We have to have a compelling vision and we need to develop stories to tell it. We have to bypass reason because the deniers do not use reason. We have to engage emotion with stories because we react to emotion. This may sound like the religionists who also argue for the bypassing of reason and intellect by appealing to faith.


However, this is not the same as faith but uses the tactic of faith. Faith uses stories and emotion because faith has no need of science, reason or evidence. Faith has nothing to back it up with. However, faith has a compelling story, it gives meaning and identity.


Climate change campaigns do have something to back them up, they are based on science and reason but an emphasis on communicating that science has lost us ground. It may be just a sad fact that the public does not respond to facts and clear communications of the science. Science and scientists themselves may not, with notable exceptions, be clear communicators. Neither are many healthcare professionals. We are unskilled in the arena of social marketing and cognitive science which could help us to understand the practices of behaviour change.  Consider that some of the major impacts on public health come not from health professionals but from legislation. Consider ‘nudge theory’ and choice architecture, consider also the manufacture of demand by transnational corporations (TNCs) and the advertising and PR lobbies. These impact seriously on population health, arguably much more than health education campaigns for which the evidence of efficacy is scarce.


Consider the role of ideology in policy making. Roger Pielke (2010) argues from his experience in the White House and as a scientist that there is not a linear relationship between science and public policy, getting politicians to understand the science does not work because they do not use science in decision making. He argues


 “if there is an iron law of climate policy, it is that when policies focused on economic growth confront policies on emissions reductions, it is economic growth that will win out every time” (p46)


Pielke points out that there is an ideological commitment and perspective that is broadly shared among policy makers, it is that there is a necessary trade off between economic growth and efforts to reduce emissions despite there being compelling arguments to the contrary. The iron law of climate policy holds everywhere in Pielke’s view. The implication (and it is not a palatable one for many) is that climate policies must be compatible with economic growth as a precondition for their success. I hope he is wrong. The new economics foundation (nef) suggests alternative economic models, as do others, however alternatives will come up against this iron law.


Joseph Stiglitz (2002), straddled policy making in the White House and was also the chief economist in the World Bank. He argues that (neoliberal) ideology drove economic policy even when there was no evidence that it worked and even when the evidence was clear that it was not working. He states:


“I saw that decisions were often made because of ideology and politics. As a result many wrong headed actions were taken” (p x).


At the IMF he argues:


“ ideology guided policy prescription and countries were expected to follow the IMF guidelines without debate” (p xiv).


Paul Simon sang “a man hears what he wants to hear and disregards the rest” as an example of a cognitive error, confirmation bias. Cognitive psychology teaches us we are prone to errors in thinking, and that we use heuristics (cognitive short cuts) to make complex decision making simple. Logic in philosophy teaches us we have a long list of logical fallacies to use when making ‘bad argument’, for example ‘argument from authority’. We do this when we accept a premise from an authority figure because they are an authority figure even if the premise has no basis in fact or evidence and even if the premise is based in a subject that the authority figure has no experience in (the ‘Bono effect’).


Ideology assists with cognitive short cuts, is riddled with confirmation bias, and has logical fallacies. Ideology needs no facts or evidence, has no reasoned analysis and is sure of it’s own rightness even in the face of counter evidence. John Maynard Keynes is said to have remarked that ‘when the facts change, I change my mind’, which is a maxim ideologues could consider.  Ideology has no use for facts, except to be very selective in the choice of facts. C P Snow argued that ‘comment is free but facts are sacred’, but ideology makes a profanity of such facts.


Neoliberalism is just such an ideology, it is dominant and is antithetical to climate science. It is also akin to faith, some are true believers in the role that ‘free’ markets, individual responsibility and personal liberty play in health and well being at individual and social level despite the evidence to the contrary. Neoliberals and climate deniers have no sociological imagination, they cannot place personal troubles in the context of public issues, the social milieu or the historical context. They are unable to see the relationship between personal biographies and structural changes in society at certain historical turns, they cannot fully understand our lives.


Markets are never ‘free’ except in theoretical form in neoclassical text books. Joseph Stiglitz helped create the notion of ‘information economics’, particularly the notion ofasymmetries of information (information is most often one sided and imperfect) and thus is arguing that free market theory is a partial, incomplete theory and is used often in the favour of vested interests such as the TNCs and the capitalist class.


In direct contradiction to their espoused theory of a small state, neoliberals use the state to crush labour demands, to socialise risk and to keep the gains privatised. We have witnessed one of the grander episodes of theft in history, a finance sector debt has been turned into a sovereign wealth debt resulting in calls for labour to pay for the failures of capital. This then leaves little room to deal with climate change because we are too focused on fixing a broken economic system as Pielke suggests.


Personal responsibility and liberty are ‘hooray’ concepts for who can deny their value in theory? However, put them into the real social world and we see that they can be used as a cover for slashing welfare benefits, pensions and wages and overt support for dog eat dog, devil take the hindmost social policy by using spurious notions such as ‘entitlement theory’. The three pillars of neoliberal ideology are rotten. Strangely, the edifice survives in right wing conservatism and tea partiers and may win the next US election. Social democratic parties of the centre left were also infected and may still not have learned the lesson.


Meanwhile the planet heats upSo, these are the challenges, what is our story? What will compel us to change? What will we celebrate? What is our bigger picture?


Kanter, R. (2009) Four tools for Defeating Denial.


Maynard Keynes, J. as quoted in Lost Prophets: An Insider’s History of the Modern Economists (1994) by Alfred L. Malabre, p. 220


Pielke, R. (2010) The Climate fix. What scientists and politicians won’t tell you about global warming. Basic books. New York.


Snow, C.P.


Stiglitz, J. (2002) Globalization and its discontents. Penguin. London.

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