Month: June 2013

Changing our mindset for health and sustainability

Changing our mindset for health and sustainability

“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (David Loy 1988 p 302).

This is also on the 2 degrees site

As I have previously suggested, health care professionals are becoming more alert to the issue of climate change and how this might affect the health of populations in the future. Climate change is only one aspect of sustainability, others of course relate to issues such as food production, distribution and security. The solutions put forward to address the myriad issues appear to be based in two different, but not necessarily mutually exclusive, approaches: 1) the technico-rational and 2) philosophical. If health care professionals are to put forward plans of action then they need to consider some of their philosophical and ideological assumptions that underpin those solutions.  I would suggest that a little more philosophical enquiry into the nature of society and our relationship to ‘nature’ just might prompt a rethink of our reliance on technical solutions.

 

The first, technico- rational, approach implicitly accepts dominant modes of thinking, which could be called ‘modernist’.  It is often based upon various philosophical traditions without explicitly critiquing them. These traditions, such as rationalism, empiricism and dualism, can be traced back to the Enlightenment and the dawn of western science. These ideas of course underpin much of modern capitalism which is another taken for granted economic model underpinned by philosophical assumptions about how the social world works.

 

A modern exponent of this is Daniel Ben Ami who, in ‘Ferraris for All’, argues that what is required is more economic development and growth, i.e. much, much more of the same, in order that humanity can better control nature and to come up with scientific and technical solutions to such issues as ocean acidification, climate change and soil erosion. Capitalism, rationalism, empiricism and dualism are implicit in this way of thinking. In short, this accepts the current economic growth based model and an understanding of how we relate to nature through extraction and development of natural resources for human use. The answer for sustainability and human health is improved technologies. I think there are flaws in this approach, one of which is that it relies too much on assuming what brought us success in the past, i.e. capitalism and technological development, will continue to do so in the future. That is to say it is based on inductive logic and its flaw; past patterns might predict the future but cannot guarantee it. As Nicolas Naseem Taleb reminded us, there might be a black swan to confound the ‘all swans are white’ logic.

 

David Loy’s comment leads us to the second approach, the philosophical, in that we might want to examine some of the assumptions that underpin the technico-rational, and especially ‘dualism’ – the separation between man and nature, mind and body. Loy contrasts Eastern non dualist philosophical traditions, with mainly Western dualism in that  “….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings” (p140). This then is a non dualist viewpoint in which ‘us’ includes the biosphere; we are indivisible as human beings from all life forms and all matter.

 

In Cartesian dualism, the Platonic tradition and the Judeo-Christian religious tradition, the self is separate from nature and is understood to be the source of awareness, meaning and value. This results in a devaluing of the physical world in which the human self is separate and superior.  The human ‘subject’ is separate from the natural ‘object’, and so what we do to ‘it’ is not part of ‘us’. Dumping toxins into the oceans is acceptable because the ocean is not part of us – it is a waste sink, we are doing something to a separate ‘it’. The human subject then becomes capable of confronting an objective world, a world which is there for our use.  The idea of human exceptualism (Catton and Dunlap 1978) – that man is special and apart from nature – takes root in this discourse.

 

This sentiment harks back to Francis Bacon, who argued in 1620 “The world is made for man, not man for the world”. In ‘The New Atlantis’ , Bacon thought that by and through the application of scientific and technological dominion over nature, men would usher in a new age of abundance and comfort.  This has echoes in Sigmund Freud’s (1927) assertion: ‘The principal task of civilization, its actual raison d’etre, is to defend us against nature’.

 

The call to have dominion over, to conquer, to harness, control or subjugate nature is predicated upon this idea of separateness from it. This control is thus predicated upon the self in opposition to nature which Yagelski (2011) calls  ‘the problem of the self ‘:  “My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”. Shabecoff (2001) suggested that concerns expressed in critiques by environmentalists of this dualist interpretation resulted in the ‘Heidelberg Appeal’ , a document signed by many scientists,  which reasserted that progress by man always involved harnessing nature to man’s needs.

However, we know that human health is inextricably bound with the physical and natural environment and what Charles Eisenstein calls ‘separation’, i.e. dualist thinking, results in practices that are injurious to us. In this regard Chivian and Bernstein (2010) argue the biodiversity is crucial to human health and I suggest that we might do better to consider ourselves part of nature not separate from it. Is it a philosophical step too far to consider that the clearing of Amazon rainforest is therefore as injurious to my health as contracting a virus?  Changing low energy light bulbs is a technical solution, perhaps I also need to change the way I think.

Masters of the Universe

Masters of the Universe

 

Here comes the sun and the moon and the stars,

The earth’s a blue marble next to bloody red mars,

And what’s in the midst of them, what’s in the night?

The mystery of gravity, spacetime and light?

And we who look up to them, we who are small,

try to explain.

 

Here comes the rain, the hail, sleet and snow,

The frost and the sea mist, the wind that will blow,

Where do they come from, where will they go?

The tides that are rising their ebb and their flow?

And we who will feel them, we who are small,

try to predict.

 

Here comes the swallow, the martin, the swift,

Migration to England over African Rift,

Monarch, Red Admiral, Humming bird moth,

Wings that worth more than any gold cloth,

And we wish to count them, we wait their return,

to summer’s long lease.

 

There goes the pilchard shoals, the Huer’s last cry,

Followed by tuna, tracked down till they die,

Cod, marlin and swordfish, monkfish and hake,

Trawler net dredging with blood in its wake,

And we who consume them, we who are blind,

add Salt.

 

Here comes acidity, salinity and methane,

oil, gas, petroleum, carbon and butane,

earth’s kept them hidden, silent for years,

why did we find them? why did we we drill?

We think we are masters, we seekers of thrill,

try to control.

 

Who is the cancer, who is the sore

on the face of our planet? Who is it wants more?

We’ve been here 5 minutes, its a blink of the eye,

Enough time to spoil, desecrate, poison and die.

We think we have knowledge, we think we have right,

we think the blue planet will turn out all right.

Just keep on consuming, just keep the cash flow

just keep on assuming, colluding but know

finite resources,

will end.

 

(cadence nicked from WH Auden’s Night Mail)

Making our own histories – we can change things if we want to and are free to.

Musing on the freedom to act in society, and on the nature of capitalism and its pernicious effects upon us, it might do to consider that we are free to change and we are not free to change. Capitalism at once exists and acts and feels like a cage while at the same time does not exist and is also only a product of our own imaginations and our social relationships that we have chosen to engage in. This matters because real lives are affected by the decisions that others in positions of power take, and they take these decisions as if capitalism is immutable, all pervading, inevitable…as a fact of life. This then justifies the use of batons, tear gas and surveillance drones in civil society and in putting down protest, and it justifies fixing the legal, financial and political framework so that big money fulfills big money’s needs.

In response to a recent email exchange I engaged in, a suggestion was made to me that there is a tendency to ‘objectify’ capitalism in many discussions – to make it seem indeed like a cage – a thing that has its own almost material existence and ‘essence’. This means that we may talk about capitalism as if it has objective existence and also a fixed nature. Capitalism is, in Emile Durkheim’s phrase, ‘sui generis’ – ‘of its own kind’. This derives from thinking that capitalist society over time replaces individuals with others, yet the ‘essence’ of society will not necessarily change. Over the course of a few decades, many individuals die and are replaced, however, the society retains its distinctive character. It is a thing of itself existing independently of individuals. An entire society that is built in this manner has its own ‘essence’. It has this ‘essence’ before any individual currently living in it is born, and is therefore “independent of any individual” existing almost as an ‘objective fact.’ We acknowledge this objective existence when we use such phrases as “Society today is worse/better than it was back in the day when…”

Some commentators might use different labels for capitalism. For example ‘casino capitalism‘ or ‘responsible capitalism‘ which reflects thier differing understandings of what capitalist society might be like. This tendency to label and to treat it as an objective fact, however, may overlook the fact that capitalism, like any ism, is dynamic and on the move. Historically that has been true: we have seen mercantile capitalism, industrial capitalism, post industrial or financial capitalism. Nonetheless and however it has been labelled, we must remember that capitalism is not an ‘objective fact’, although it can certainly feel that way especially to those who feel the full force of economic decisions made in far away board rooms.

Capitalism is a dynamic ever changing social system which finds expression and manifestation in human social relationships. The ‘objectivity’ of capitalism is a chimera; we may reify it and miss the essential nature of human decision making and social relationships that underpins it. Susan Strange argued “economists simply do not understand how the global economy works” due to a poor understanding of power and an over-reliance on abstract economic models. In other words, economist are apt to treat capitalism and the working of markets based on a false premise: that there is a objective system that can be understood theoretically using mathematics and a theory of self interested utility maximising rational actors, the ‘homo economicus’ of JS Mill and Adam Smith. To be fair to Smith he tempered this view in his Theory of Moral Sentiments.

What economists often miss is that what we are talking about here is a set of human relationships characterised by an imbalance of power.

“Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past” (Marx). What have ‘we’ been given and transmitted from the past? Anti capitalist sentiment such as some of us in the sustainability or others in the Transition Towns movements express, are confronting Big Oil, and a cluster of high carbon social systems (John Urry) which are based on certain capitalist relations of production. ‘We’ ignore capitalist class relations at our peril. ‘We’ may confront power elites who have made, and are trying to continue to make, history in their own image: how that history will pan out depends on our collective and individual responses to Power, e.g. the Military-Industrial-Security complex, the World Bank, IMF, OECD, G8, Davos, Bilderberg (?), EU and other Regional blocs, the Trioka, the Corporate Class Executive and the Political Power Elite. We, e.g. ‘anti-capitalists’ or the Transition Towns or Environmentalists, are trying to remake history; history as we please, but within a certain socio-political context and power play not of our choosing. We do not have ‘self selected circumstances’ and that is what makes capitalism feel like a cage. Ask yourself: who has the guns?

For an example of circumstances being shaped by the powerful, note how successful the right wing press has been in sowing the seeds of doubt in the population about climate change,  and also for blaming the poor for their position while supporting austerity in the midst of one the greatest transfers of wealth from poor to uber rich (the 0.01%) we have seen, and the movement of private bank debt to sovereign public debt. There is ample evidence that the neoliberal agenda, which unites many of groups mentioned above, are antithetical to a ‘no growth economy’ and to social democracy.  In the West, there is only one game in town: growth based on neoliberal economics.

There are countervailing voices, e.g. Paul Hawken’s ‘Blessed Unrest’,  but some are increasingly despairing, Will Hutton articulates this well.

The post financial crash shifts of 2008 are playing out, but we don’t know in 10 years what this will look like. So far however, report after report shows the wealthy elite entrenching their power and wealth* while the occupy ‘movement’, the indignados, the precariat, come under increasing demonisation, e.g. skivers v strivers, surveillance and crack downs, using para militiary type tactics. The monolith of Capitalism stands while we crash against it.

Capitalist social relationships are backed by ideology and often force. Some argue it is the best of a bad lot, and that like democracy it is the worse system we have except for all the others, that it is the only game in town. Marx himself marvelled at its ability to produce abundance. However, is this really the best we can do? Is this really the best world in the best of all possible worlds? Growth capitalism, and there is no other sort, is leading us towards ecological disaster, while the social determinants of health result in inequalities in health whereby millions die prematurely and needlessly because of our socio-political arrangements.  Many of us bluster and blog and rage and rant and protest, some of us quietly get on with living differently, remaking our social relationships as best we can.

We are free but everywhere we are in chains.

 

*the richest 1,000 persons, just 0.003% of the adult population, increased their wealth over the last three years by £155bn. That is enough for themselves alone to pay off the entire current UK budget deficit and still leave them with £30bn to spare.

2degrees

2degrees is a network for sustainability professionals. From their website:

“We believe that the world economy is changing very rapidly. Like the CEOs of companies such as Walmart,NikeTescoP&G and Unilever, we believe that to survive and grow, businesses must start to operate sustainably.

In this changing world, sustainability is increasingly a source of competitive advantage, driving growth, efficiency and profitability. Within years there will be no need to talk about ‘sustainable business’. All businesses will be sustainable, or not in business at all.

Sustainable business is no longer the sole preserve of sustainability professionals. Business people across all disciplines are recognizing the opportunities presented by sustainable thinking. Because of this, we provide services to both sustainability specialists and other business professionals.

We believe that the answers to our sustainability challenges are out there, somewhere. What is needed is the ability to connect up organizations, people, ideas, experiences and solutions, and the desire to change. Social media technologies can help do this on a massive scale – and managed communities like 2degrees will accelerate the change”.

There are of course arguments to be had about whether some business models are sustainable, or whether corporate and finance capitalism can ever be sustainable given their need for growth. This is a theme that underpins a good deal of my thinking.

However, I have become a guest blogger on the site and my first post goes up very soon. In this short piece I outline the link between climate change sustainability and health and set out the position for many health care professional and educators.

An unachievable utopia in nursing practice? Utopia will not be paid for by the ‘Greedy Bastards’

The Politics of Nursing: Care is expensive: get used to it.  

Introduction

By now many nurses will be feeling a mixture of despair and insult they have received following the many reports into poor quality care. These feelings can lead to disenchantment, disengagement and disillusionment with both politics and health care delivery. Jane Salvage (1985) suggested that nurses ‘wake up and get out from under’ and while recognising that for some this past entreaty to engage politically may further entrench those feelings, the need for nurses and nursing to do so has not diminished. As Stuckler and Basu (2010) argue, government policy becomes a matter of life and death as ‘Austerity is killing people’. Nurses are part of the front line in promoting health and caring for those who are ill or living with chronic conditions. Their work is therefore framed by politics and political decisions. The bottom line is that there is a ‘bottom line’ to care, societies prioritise resources depending on their values, however there is not a level playing field in this regard. Care is under resourced, undervalued and often invisible. As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care Nursing must ally itself with the progressive forces which seek to redress the balance forces of power which currently results in gross inequalities in health and poorly funded care provision. In this article I wish to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from progress in care giving.

The Politics of care

This summary of a recent article by Curtis (2013) is worth reading as it sets up what some are experiencing as they struggle to reconcile care and the cultures that surround it:

“Nursing faculty are facing challenges in facilitating student learning of complex concepts such as compassionate practice. There is currently an international concern that student nurses are not being adequately prepared for compassion to flourish and for compassionate practice to be sustained upon professional qualification…..nurse teachers recognise the importance of the professional ideal of compassionate practice alongside specific challenges this expectation presents. They have concerns about how the economically constrained and target driven (my emphasis) practice reality faced by RNs promotes compassionate practice, and that students are left feeling vulnerable to dissonance between learned professional ideals and the RNs’ practice reality they witness”.

A key point made in the article is that of the requirement for strong nurse leadership in clinical practice to deal with those factors that make care and compassion difficult to practice fully. That being said, no amount of good leadership will address the basic problem of the cost of caring: ‘who pays?’ Poor quality care is the fault of the person giving it, personal accountability for neglect and abuse cannot be sidestepped. However, we need to bring our sociological imaginations to bear so that we can more fully understand the antecedents to abusive institutional care. These include poorly funded care provision for a low status Cinderella service.

Too much of the discussion of the failings in care do not take into account the political economy of care in societies and the historical antecedents that have brought us to where we are. Instead, we get discussions around changing ‘cultures’. Reconciling professional ideals to actual practice is very difficult given the organisational cultures many nurses work in, and the almost grudging support given to nurses by the political system set up by what Graham Scambler (2012) calls the Corporate Class Executive (CCE) and the Political Power Elite (PPE). The bottom line, and that is a phrase the CCE recognise, is that care costs money. One of the critiques of the Mid Staffs tragedy was that corporate self-interest was put ahead of patients’ safety (Francis (2013).

There have been many reports regarding the health and social care of elderly people and it seems to be that their needs are outstripping both private and public provision for them. J K Galbraith coined the phrase ‘private affluence-public squalor’ to describe the mismatch between what is resourced in the private sector and the public:

There’s no question that in my lifetime, the contrast between what I called private affluence and public squalor has become very much greater. What do we worry about? We worry about our schools. We worry about our public recreational facilities. We worry about our law enforcement and our public housing. All of the things that bear upon our standard of living are in the public sector. We don’t worry about the supply of automobiles. We don’t even worry about the supply of foods. Things that come from the private sector are in abundant supply; things that depend on the public sector are widely a problem. We’re a world, as I said in The Affluent Society, of filthy streets and clean houses, poor schools and expensive television. I consider that contrast to be one of my most successful arguments”. (interviewed in 2000).

Galbraith first wrote about this process in 1958.

As governments embrace austerity policies, this tendency for capitalism to funnel resources, research and development into goods and services that make a return while ignoring public provision for those things that do not have immediate impacts on improving shareholder value or the price of stocks, increases. Care is seen as a cost and not a benefit to those who decide where the investments should be made. Private care companies will provide care with an eye to the balance sheet. This results in hiring under educated and poorly trained staff who too often lack supervision and development in high patient to staff ratios (Salvage 2012). The NHS is no different, but is also now handicapped by various factors making its provision seemingly expensive for society. While the current (2013) Chancellor states that NHS spending will be ringfenced, the true position is that care straddles both health and social care sector provision and is thus characterised by means testing.  It is accepted fact that our population is ageing with forecast increases in dementia and diabetes, health and social care services will experience increased pressures as demands and frailties rise. The argument is about who is going to pay for the provision of care?

Frail elderly people need a lot of care and that care is expensive. Let us not forget our history – why the NHS was set up (Abel Smith 2007), who struggled to get it in into place and why, and the functions women especially played in the private sphere (Elshtain 1981) of care both for children and the elderly. Modern Industrial society was both capitalist and patriarchal with care firmly in the private domain. No state funding as we would recognise it was provided because this was expensive. Patriarchal attitudes would not define it as ‘proper’ work and so could be left to women. The Parish, Poor laws and workhouses were the backstop for those unable to fend for themselves, for those without the family, and that often meant women, looking after them. The working class had to struggle to get health and education properly funded. Enlightened Victorian philanthropists and entrepreneurs realised that if they wanted workers to keep working then recreation and education had to be provided. This provision was despite the capitalist dynamic for profit, not because of it.

We have come a long way as social democratic pressures finally provided the NHS and Education, as the elites also were won over to the need to provide care. The ‘One nation’ Tories at least understood that a prosperous society had to take care of all of its members, of course there was some self interest in this – we needed soldiers who were fit for the battlefield, and we needed healthy workers for the factories. This is a simplistic history as it is more nuanced than this. However, over the last 30 years or so we have seen reversal of this enlightened social democratic outlook on care and public health and care. The need for care is increasing but this is occurring just when the elites are pulling back from their responsibilities. They look at what state provision will cost for high quality elder care and are frightened.  They also have a visceral loathing of state provision…because it costs them money through taxes they do not want to pay. They say it is because the state is inefficient and anti-democratic, that state provision is the road to serfdom. Suffice to say that the current involvement of the CCE with the PPE is extremely antidemocratic but their right wing press cheerleaders have not spotted it or prefer to ignore it.   Seamus Milne  has eloquently exposed how corporate power is corrupting politics.

The neoliberal capitalist agenda (Crouch 2011) requires the state to pull back from earlier involvement on education and health. The CCE and the current PPE have swallowed an ideology that simply accepts private provision = good, public provision = bad. This is why we are seeing the conditions of an affluent society being characterised by a hugely increasing wealth gap. This agenda also allies itself with patriarchal views on the proper role for women – get back in the kitchen girls and look after the kids…and now, of course, Gran as well.

Austerity is now the smokescreen for dismantling of the state provision for care. Does this mean that lack of compassion is directly related to neoliberal policies?  To accept that is to think in an overly simplistic cause effect relationship. Societies are more complex than that.  Of course poor quality care pre dates capitalism and the NHS, however capitalism (and its often hidden twin patriarchy) sets the agenda and the organisational forms and institutional arrangements in which care takes place. This now means as budgets get cut and savings asked for, nurses will be asked to provide more for less. This has been always the case; nursing work as womens’ work (Hagell 1989) has largely been invisible emotional labour (Smith) which has been poorly paid and supported, instead their rewards have been patronising labels such as ‘Angels’. Nurses know what they need to provide care and they can do it if given supportive organisational cultures and the power to actually direct, organise and manage care properly.

As Roy Lilley argued on nhs.managers.net:

(The Francis report 2013) talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have stood still.

and…

“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

And there you have it. Do the austerity addicts think it is the proper role of the state to fund the front line. No, they hanker after a US style private provision with the family, the big society volunteers and women to take up the slack. That will not wash in a hospital ward or a care home full with frail elderly patients.

Nurse educators and their students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, disdain apart from those engaged in teaching the social sciences in nursing. I would argue that nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. It might be fair to suggest that since about the 1980’s both feminism and social democratic politics took their eyes off the ball or felt that because progress had been made the struggle was nearly over.  It is not. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Caring is not sexy – it is not fancy infrastructure projects, it does not make millions at the click of a mouse;  hedge funds and private equity firms don’t crack champagne bottles over the needs of the frail elderly. Care is unglamorous emotional labour, involves often dirty body work, offering little in the way of recognition and prizes – there are no Golden Globes, Oscars or Baftas. There is no end point, no project that is completed and shown off, no bonuses to be earned. ‘Top’ Universities show off their ‘top’ professions: law, medicine, business and science whose courses are oversubscribed due to professional closure and the high salaries they attract. The children of the elite are groomed and public schooled to ensure they attend the ‘right University’ and study the ‘right’ subject while eschewing nursing, which struggles to gain academic credibility and value among society and Russell group elites, while its core concept is seen to require no education at all.

Nurses are in a political struggle whether they realise it or not. For the sake of all us who will require care, don’t let the greedy bastards grind us down

 

 

 

 

 

References:

Abel Smith, B. (1992) The Beveridge Report: its origins and outcomes. International Social Security Review 45 (1-2) pp5-16

Curtis, K. (2013) 21st Century challenges faced by nursing faculty in educating for compassionate practice: Embodied interpretation of phenomenological data.   Nurse Education Today, http://www.nurseeducationtoday.com/article/S0260-6917%2813%2900170-6/abstract

Elshtain, J. (1981) Public Man, Private Woman: Women in Social and Political Thought. Princeton, NJ: Princeton University Press

Scambler, G. (2012) Elements towards a Sociology of the Present. December 6th http://grahamscambler.wordpress.com/2012/12/06/elements-towards-a-sociology-of-the-present/

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