Month: October 2014

Global Health: Universal Health Coverage

Universal Health Coverage (UHC)

A report just published on UHC (Maeda et al 2014) is a synthesis of case studies from 11 countries experience of UHC.

 

 

“The goals of UHC are to ensure that all people can access quality health services, to safeguard all people from public health risks, and to protect all people from impoverishment due to illness, whether from out of pocket payments for health care or loss of income when a household member falls sick”. (p1).

The 11 countries are committed to the goals of UHC, and are willing to explore  and share their experiences with others. While each country’s health system  brings its own unique history and confronts its own set of challenges, each  country’s experiences offer valuable insights into some of the common challenges  and opportunities faced by other countries at all stages of UHC.

The Key Policy Messages in the document are:

• Strong national and local political leadership and long-term commitment are required to achieve and sustain UHC. Adaptive and resilient leadership is required, capable of mobilizing and sustaining broad-based social support while managing a continuous process of political compromises among diverse interest groups without losing sight of the UHC goals.
• Countries need to invest in a robust and resilient primary care system to improve access as well as manage health care costs.
• Investments in public health programs to prevent public health risks and promote healthy living conditions are essential for effective and sustainable coverage.
• Economic growth helps with coverage expansion, but is not a sufficient condition for ensuring equitable coverage. Countries need to enact policies that redistribute resources and reduce disparities in access to affordable, quality care.
• Countries need to take a balanced approach between efforts to generate revenues and manage expenditures, while expanding coverage.

The 11 Countries in the UHC Study

Bangladesh
Ethiopia
Ghana
Indonesia
Peru
Vietnam
Brazil
Thailand
Turkey
France
Japan

Comment.

The Asset approach to health emphasises community ‘assets’ and seeks to mobilise those to support health and well being. The UHC approach is about health care services which is the other side of the coin and focuses on dealing with illness and disease. The social determinants of health emphasise the conditions in which people are born, grow, live, work and die. These conditions are characterised by imbalances of money, power and resources at national and global level.

The UCH project thus seeks to address the health impacts of social conditions and does so by explicitly acknowledging the need for a redistributive orientation to the use of resources. This brings it firmly into the political sphere where the business of decisions around provision of health services, or rather ‘illness services’, occurs through the action of more or less powerful stakeholders. Graham Scambler’s ‘Greedy Bastards Hypothesis‘ illustrates the power of certain vested interest.

The UCH approach also is explicitly based on growth models of economic development , which for many countries is entirely appropriate, but for high carbon developed nations may be less so due to their past contributions to carbon emissions and their current continuing high level carbon footprints.

Thus the UCH approach needs to be seen in this context, that it is just one approach to health and makes assumptions about political economy.  The UCH may or may not directly challenge the powerful players and vested interests whose primary aim is capital accumulation and ‘accumulation by dispossession‘ which adversely affects the health of populations through stripping them of health assets.

The unlearned, fed by the unscrupulous, led by the clueless.

The unlearned, fed by the unscrupulous, led by the clueless.

 

 The economies of Europe and the US are still feeling the after effects of the financial crisis of 2007/8. Next week midwives go on strike for the first time in their history, other NHS workers have been denied a 1% increase in pay. In the US over 13,000,000 foreclosures, i.e. banks taking back property on mortgage defaults, were filed since 2007. There is evidence that China is following the US in experiencing housing bubbles. Although ‘growth’ has resumed in the UK, the nature of recovery is weak and is still based on the system that crashed in the first place. For the first time ever the majority of people in poverty are working while the government subsidises business to the tune of £85 billion. Britain First has 500,000 ‘likes’ on Facebook; neonazis in Neasden, Northampton and Newcastle.

 

Meanwhile UKIP preach that our salvation lies in curbing Immigration and getting out of the EU. That has about as much credibility as waiting for the Messiah, and is as useless as a bible in a whorehouse. It would be government by ‘white van man’ who doesn’t like ‘darkies’ coming over here and stealing our right to petty nationalistic ignorance.

 

The political response is weaker than pissed gnat and only half as intelligent. It is predicated upon assumptions and theories about how the economy works that either focus on the supply side (neoliberal economics) or the demand side (Keynesian). In other words, one side see that policies are put in place to revive the supply of jobs and products through low taxation, cutting back public spending to reduce government debt, removing state regulation and curbing the power of labour in an attempt to unleash the creative forces of capitalism. This is the neoliberal response and has been dominant since about the 1980’s. The other side, Keynesian demand management, focuses on more public spending, increasing worker’s wages, investments in new technologies, education and infrastructure to stimulate demand. Demand then stimulates growth with which to pay back the governments’ borrowing. This was dominant from about the late 1940 until the 1970-80s. However each attempt produces a crisis in the system that requires a resolution. This is economic orthodoxy, which is only now being challenged by post crash economics in Manchester. However, way back in the 1980’s the humble Plymouth Polytechnic was teaching unorthodox political economy (Marx, Veblen, Galbraith) while Russell group elites were mired in neoliberal classical economic theory.

 

Orthodoxy has not analysed the underlying contradictions of capitalism or understands it as a dynamic system. Crises in capitalism, e.g. too much worker power or too much Capital power, do not get solved as much as moved around the globe.

 

So if we want to understand the current economic mess we are in, we need to try and understand the underlying dynamic and systemic processes at work.

 

I don’t think this is going to happen in the short to medium term because the general population likes its politics in bite-sized chunks based on slogans and soundbites and a bit of showbiz. The myopic media know this and pander to this tendency by presenting us with a woeful lack of analysis and baking.

 

Political parties in the UK: Tory, Labour, Lib-Dem, UKIP are all united in accepting economic orthodoxy either in its neoliberal form or its Keynesian form. All accept growth as the key objective indicator of success, and growth measured in GDP terms. Only the Green party challenges growth but even then are often hazy on the underlying dynamics of capitalism and so are in danger of ‘greening the capitalist machine’ which is of course an oxymoron. It cannot be done.

 

What is required is hard work. We need to get our heads around how capital goes about its business, to understand that contradictions are inherent within it and that right now there are three dangerous contradictions that could wreak havoc on civilised societies around the globe:

 

  1. Endless Compound growth (exponential growth).
  2. Capital’s relationship with nature (consumption is killing us)
  3. Universal Alienation: the revolt of human nature.

 

 

So for now, know that you are being fed bullshit, lies and myopic analysis leading to the Clacton bell being rung for the victory of the disenchanted, uneducated and alienated ‘consumer citizen’ looking for a scapegoat.

 

 

 

 

See: David Harvey 2014 ‘Seventeen Contradictions and the End of Capitalism’.

 

Nursing care scares and Moral Panic

Nursing, Care scares and Moral Panic.

 

The number and tone of reports of poor quality care (e.g. Simmons 2011) especially, since the Mid Staffs NHS trust inquiry but by no means is defined by it, may be described as a moral panic and has been described as a crisis in care (Hari 2011, Phillips 2011a, 2011b) and “reveal a moral sickness in the professional ethic of nursing, and more particularly nurse training…” (Phillips 2011b). These media reports over poor quality care (Marrin 2009, 2011, Shields et al 2011) and the identification of graduate nurses as folk devils who are “too posh to wash”, lead us to ask why this moral panic over graduate nursing has arisen?

 

A ‘moral panic’ is when a population feels the ‘social order’ is threatened, and that this threat is felt intensely, it is a certain reaction to a perceived social problem. A moral panic may be characterized by irrational, inappropriate overreactions to problems. Stanley Cohen (1972) applied the term to press reports and establishment reaction to the phenomenon of ‘Mods and Rockers’, a moral panic arises when:

 

“a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” (Cohen 1973 p9). The scathing criticism of graduate nursing in the press looks very similar to this sort of description. So, what societal values and interests are thought to be threatened by graduates?

 

The first aspect is that some feel a loss of ‘the proper place of women/nurses as mother archetypes’ which is part of the longer term process of female entry into the labour market and the break from domestic duties. Feminism has been blamed for this process (however the requirements of consumer capitalism and the need for labour has also had its effects).

 

The second is the ambiguities felt over the care of elderly people which increasingly has been seen to be the State’s proper role since the introduction of the Welfare State. Although the expressed social order demands that care of the elderly be done within families, the economy demands labour mobility resulting in geographically fragmented families unable to care for elderly relatives. The loss of the family wage and the rise of consumer culture also affects our abilities to care for both children and the elderly as both parents work. The actual social order is that elderly people are, en masse, in institutions and that allows us to abrogate our responsibilities. Although no one expresses a wish to be in a nursing home, no-one either wants (or is able) to take responsibility for elder care.

 

The third aspect is that body work which involves intimacy, closeness as well as dirt and disgust, is again seen as female caring work which does not attract any social value or support beyond expressions of stoic heroism on behalf of carers.

 

Graduate nurses challenge these conceptions by being women who are educated, who work and expect like any other professional to be rewarded for their efforts, there is then a cognitive dissonance between on the one hand a vision of nursing as self sacrificial angels and as professionals requiring proper education and reward as professionals. One way to solve this dissonance is to reframe professional nursing, i.e. ‘train’ them in hospitals (putting them in their ‘proper place’).

 

However, the place of women, and women as nurses, the ambivalence towards care and its meaning, the increasing marginalisation of the elderly and their devaluing may be manifestations of society’s turn from solid to ‘liquid modernity’ (Baumann 2000). Social values, aspirations and expectations are played out within the themes of globalization, individualization, marginalisation, poverty and consumerism. These are the actual social threats that this moral panic cannot actually name and identify. ‘Folk devils’ have to be found to explain these new forms of alienation. Poor care has been around as long as there have been carers, and so we need to be careful not to argue that liquidity causes poor care, rather it may the case that liquid social conditions predispose individuals to perform in particular ways and for their actions to be interpreted in particular ways. The folk devils are in, this instance, graduate nurses. However, blaming nurses refocuses attention away from more difficult problems and gives easy solutions (‘return training to hospitals and all will be well’).

 

Liquid modernity, according to Baumann, involves community fragmentation, eroding social bonds, atomized relationships and individualistic expectations all in the context of the globalization of capital and markets which dislocate communities. Workers have to respond to calls for mobility and flexibility or face redundancy. Communities struggle to reconcile competing demands especially with the increasing numbers of elderly people and costs of care. Nurses and midwives find themselves caught between all of these competing demands unable to make the links between their individual experiences and larger social conditions,

 

If only one nurse abuses a patient we should properly look to the character of the individual nurse for reasons.  When cases of reported abuse become legion then the personal troubles of the patients should be seen in the context of the public issues of society. To fully comprehend the position of the abuser we need to address their personal biography and history and the relationship between the two in society. Anyone wishing to analyze why there is poor care needs to avoid simplistic knee jerk moral panic type reactions and grab the idea that nurses can understand their experiences and gauge their fates only by locating themselves within their period, that they can know their  own lives only by becoming aware of all those nurses in the same circumstances. Focusing on the personal accountability of care staff without addressing the structural conditions in which they work simply will not do.

 

So what then is the answer?

 

Care has to be really valued, and in current society the main way value is ascribed is to place a monetary value onto it and bring it centrally into business planning. Therefore the cost of care has to be brought into all accounting. Capitalist production currently does not take into account the care (and environmental) costs that society bears for that production. However caring still has to be done or else production cannot continue in its current form. This is not a new argument, feminists and environmentalists have been arguing this for years. If society wishes to value care then it has to pay for it. That means increasing the number of staff and paying them a competitive wage so that good quality staff are educated, retained, supervised, developed and valued. Or, as Sue Gerhardt (2010a) agues we should refocus on caring as a real social value and perhaps introduce a ‘caring wage’ (2010b) say £12,000-£16,000 per year? Society has to value care with more than lip service and the stoic angels tag, but in the current economic setting social values are not strong enough to ensure we will do this.

 

 

 

 

 

 

 

Baumann Z. (2000) Liquid modernity. Polity. Cambridge.

 

Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin, p.9

 

Gerhardt S. (2010a) The Selfish Society. How we all forgot to love one another and made money instead. Simon and Shuster. London.

 

Gerhardt S.(2010b) The Selfish Society. RSA events. 22nd April. http://www.thersa.org/events/audio-and-past-events/2010/the-selfish-society

 

Hari, J. (2011) The plan to resolve our care home crisis. The Independent January 26th http://tinyurl.com/5ugyond

 

Hawken P (1994) The Ecology of Commerce. Harper Collins. London

 

Marrin, M. (2009) Oh Nurse, Your degree is a symptom of equality disease. The Sunday Times. November 15th

 

Marrin, M. (2011) Our flawed uncaring NHS is a self inflicted wound. The Sunday Times. May 29th

 

Phillips, M (2011) The moral crisis in nursing, voices from the wards. Daily Mail. October 21. http://melaniephillips.com/the-moral-crisis-in-nursing-voices-from-the-wards

 

Phillips, M. (2011) How feminism made so many nurses to grand to care. Daily Mail. October 17. http://melaniephillips.com/how-feminism-made-so-many-nurses-too-grand-to-care

 

Shields, L., Morrall, P., Goodman, B., Purcell, C. and Watson, R. (2011) Care to be a nurse? Reflections on a radio broadcast and its ramifications for nursing today. Nurse Education Today. doi:10.1016/jnedt.2011.09.001

 

Simmons, M. (2011) Poor Nursing care. NursingTimes.net. 4th July. http://www.nursingtimes.net/poor-nursing-care/398.thread

Greedy Bastards and Health Inequalities

GBH: Greedy Bastards and Health Inequalities by Graham Scambler. Find it here: http://linkis.com/wp.me/Iv4tk     Posted on November 4, 2012

 

 

Student nurses will be introduced to the Social Determinants of Health (SDoH) approach as outlined by the World Health Organisation (2008) and in the Rio declaration in 2011. The reason for this is that the UK’s Nursing and Midwifery Council state in their standards for education (2010):

 

All nurses must understand public health principles, priorities and practice in order to recognise and respond to the major causes and social determinants of health, illness and health inequalities. They must use a range of information and data to assess the needs of people, groups, communities and populations, and work to improve health, wellbeing and experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social inclusion”.

 

The World Health Organisation states: “The Social Determinants of Health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries”.

 

I think this introduces an ethical imperative and a socio-political role for nursing (Falk-Raphael 2006) as the NMC explicitly state that nurses are to “work to improve health….”. If health has social determinants based on the ‘distribution of money, power and resources’ then nurses are required to understand what this means. Indeed public health principles are now embracing concepts such as the SDoH and going further in the Ecological Public Health approach (Lang and Rayner 2012) than traditional biomedical approaches to public health.

 

So what is the connection between this and the ‘GBH’?

The GBH asserted that health inequalities in Britain are first and foremost an unintended consequence of the ‘strategic’ behaviours at the core of the country’s capitalist-executive and power elite. This is where health gets political. The strategic behaviours include getting governments to reduce state regulation, tax, control, ownership and provision for public services in order to facilitate the transition to corporate ownership, provision and control of public goods such as health and education. These corporations include Mitie, Serco, GE, Virgin and Capita. They are currently negotiating the Transatlantic Trade and Investment partnership (TTIP) between the US and the EU in order to make it easier to engage in business across the Atlantic. The TTIP will also allow corporations to sue national governments if they try to block renationalisation of health services, or if they engage in environmental or social regulations that is perceived to hurt business.

 

Scambler argues that the ‘capitalist class executive’ (CCE) are a core ‘cabal’ of financiers, CEOs and Directors of large and largely transnational companies, and rentiers. This ‘cabal’ has come to exercise a dominating influence over the state’s political elite including those in government. Quoting David Landes, Scambler suggests:

“men of wealth buy men of power” who then enact state policy which supports their activities and interests.

The GBH suggests that the activities of capitalists and politicians result in ‘homicide’. Indeed Stuckler and Basu (2013) argue that the government policy of ‘Austerity kills’. Michael Marmot makes similar claims about government policies.

The GBH is based on an analysis of social structures, the class relationships, which benefits the core members of Britain’s rapidly globalising capitalist class executive. Scambler argues:

“financial capitalist Britain is characterized by a revised ‘class/command dynamic’ whereby class interests exercise greater sway over state policy and practice than hitherto”.

In other words, a ruling class can now exercise power and control, and can command the political state, in a way that they could not previously do so. Since the advent of the Welfare State, with its vanguard the Attlee labour government in 1945, the power and control of the CCE was tempered by social democratic forces acting below. However, the Thatcher-Reagan victories paved the way for an assault on social democratic control of the state and opened up a path for the CCE to further their interest through the capture of political levers of control.

Scambler argues that:

“anyone who doubts the thrust of this argument (should put forward) a more telling macro-analysis of the journey of the (English) Health and Social Care Bill into law in March of 2012. This Act is re-commodifying health care. Without mandate…the ConDem coalition is turning the NHS over to predatory US-style for-profit companies”.

So, the CCE are acting strategically to create a health environment conducive to corporate interests and profit; they are not interested in the social conditions of everyday life. Their activities result in the slow withdrawal of health and welfare provision by governments to allow them to provide services so that they can make money. They are helped in this by government ideology that abhors state provision for public goods such as health, education and transport, and is focused on deficit reduction through a reduction in the welfare bill. The CCE do not exist to address inequalities in income or wealth or to better the circumstances in which people are born, grow, live work or age. Their primary purpose is capital accumulation which results in periodic financial crises.

He goes on to suggest that the type of health care organization (private hospital or public hospital) and delivery (e.g. GP access) available to people is not decisive for health inequalities. In other words, differential health outcomes (mortality and morbidity rates) are based in the conditions and experiences of everyday lives, and this shows a social gradient – i.e. the lower down on the socio-economic scale you are, the worse your health outcomes.

Thus current arguments over the structure, funding and function of the NHS, is only part of the story for people’s health. We must also look to the actions of the CCE and social class relationships. It is in class relationships, and the power and action of the CCE, that we see ‘asset flows’ working in people’s lives and affecting their morbidity and mortality rates.

Scambler argues;

“The noun ‘flows’ is significant here. People do not either have or not have assets positive for health and longevity, rather the strength of flow of these assets varies through the life-course”.

So it is not about the static acquisition of wealth or material deprivation that is at work. It is about what assets flow in and out of people’s lives over the course of their life, and this is particularly important in childhood and older age.

The ‘assets’ are:

  • biological, your ‘genetic inheritance’, sex, your disabilities, your long term conditions.
  • psychological, your self-efficacy, locus of control, learned helplessness.
  • social, your family network, community networks, friendships.
  • cultural, your lifestyle choices such as smoking, or ethnic background
  • spatial, where you live, leafy Surrey or inner city Glasgow?
  • symbolic, your status as a ‘chav’ or as member of the elite.
  • Material, your income and wealth.

It is important to stress that a strong flow of one asset can compensate for the weak flow of another.

Scambler provides examples: ‘a strong psychological asset flow (i.e. high personal resilience) can cancel out the negative propensities of a weak flow of social assets (i.e. an absence of close-knit social networks); and a strong flow of symbolic assets (i.e. high social status) can mitigate the damage liable from a weak flow of spatial assets (i.e. living in a deprived neighbourhood).

 

 

 

 

In addition, Scambler suggests  that we need to understand that:

 

  1. the strength of flow of material assets (i.e. standard of living via personal and household income) is paramount. This links with the material deprivation thesis explaining the link between health inequalities and socioeconomic status.
  2. flows of assets tend to vary together (i.e. mostly strong orweak ‘across the board’);
  3. weak asset flows across the board tend at critical junctures of the life-course (e.g. during infancy and childhood) to have especially deleterious effects on life-time health and longevity: a child born with a chronic illness, into the lowest decile of income distribution, in an abusive psychological and social environment, living in damp squalid housing in which both parents smoke, in an area of high unemployment and poor access to health care and a proliferation of fast food outlets, in a culture that demonises ‘chavs and benefits cheats’…….
  4. weak asset flows across the board, and I daresay strong asset flows across the board, tend to exercise a cumulative effect over the life-course  (negatively and positively respectively);
  5. the ‘subjective’ evaluation of the strength of an asset flow can exert an effect over and above any ‘objective’ measure of that flow (e.g. a symbolic asset flow perceived as weak relative to that enjoyed by an individual’s reference group can be injurious in its own right). That is, how we perceive how good or poor our ‘asset’ is, affects us even if that asset is not in itself injurious. This is the social comparison thesis or psychosocial hypothesis.

 

Scambler regards the material asset flow as vital or ‘prepotent’. Of all assets it is the material conditions of life that underpin much of our health outcomes.  In this, Scambler is adopting a Marxist take on health inequalities. To argue that material conditions underpin all other asset flows is not to diminish their importance for health inequalities. This is  only highlighting the key point of Wilkinson and Pickett’s The Spirit Level, in that that action on the reduction in income inequality is a precondition for tackling health inequalities.

Danny Dorling (2014) points to the rising levels of inequality and argues that being born outside the 1% has a dramatic effect on a person’s potential – their asset flows – reducing life expectancy, limiting educational and work prospects and adversely affecting mental health.  The CCE are of course not the 1%, they are part of it but their wealth puts them more into the 0.01% of income earners.

Scambler suggests:

“This last point takes us back to the GBH and the class/command dynamic that underwrites it. Our society, one in which income and health inequalities are rapidly rising, and in which policy…has allowed a Health and Social Care Act to deliver a proven cost-effective publicly-owned NHS into the hands of transnational profiteers, is slipping into a post-welfare-statist, neo-liberal abyss”.

 

In other words, UK society is losing its NHS as it is being sold off piecemeal to private sector providers who seek to make a profit,  losing its welfare provisions, is experiencing increasing social and economic divides and which are the ‘circumstances shaped by the distribution of money, power and resources’ impacting on population health. The CCE of course do not need the welfare state or the NHS as they inhabitRichistan’ providing them with private health and ‘concierge’ doctors.

Finally, a nurse argues;

“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006)

 

So there you have it, a call to engage politically to address the actions of the CCE and the political power elite to call them to account and to change social and economic conditions that result in inequalities in health.

©Benny Goodman 2014

Communicating in contemporary culture: Climate Change and Health

Communicating in contemporary culture.

 

Jon Snow, the channel 4 journalist, chaired the morning’s panel discussions at the BMJ’s ‘Health and security perspectives of Climate Change’ conference held at the BMA in London on Monday 17th October 2011. 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 at the conference 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 and by implication other health professionals, 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.

A word of warning though. George Lakoff (2008), George Marshall (2014) and Noami Klein (2014) all describe in slightly different ways that this is almost a ‘culture war’ in that there are powerful vested interests who so far have dominated public discourse with a pro growth, small state, anti climate change message.

 

 

 

Klein N (2014) This changes everything. Climate vs Capitalism. Allen lane London.

Lakoff G (2008) The Political Mind. A cognitive scientists guide to your brain and its politics. Penguin. London.

Marshall G (2014) Don’t even think about it. Why our brains are hard wired to ignore climate change. Bloomsbury. New York.

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

On Climate Change

On Climate change

The health effects of climate change

The role of the nurse in addressing the health effects of climate change

“To mobilise people this has to be an emotional issue. It has to have the immediacy and salience. A distant, abstract, and disputed threat just doesn’t have the necessary characteristics for seriously mobilising public opinion.” Daniel Kahneman in Marshall (2014 p57). He stated “I am deeply pessimistic. I really see no path to success on climate change”.

 

Climate change needs:

 

  • Salience – qualities that mark it out as prominent and demanding attention, something concrete, immediate and indisputable. Climate change is none of these things for the mass of the population.
  • Acceptance of short term costs to mitigate uncertain long term losses. This is something we are not prone to do.
  • Certain and uncontested information. As long as billions of $ in the US and the UK support denial and the vested interests of the fossil fuel lobby in media this remains at the level of popular culture, and in politics, uncertain and disputed. Those with the power and finances to affect change do not want to do so as it is perceived to threaten their base values.

 

People, however:

  • Are more averse to losses than gains. If changing to a low carbon lifestyle means giving up the car, air travel, eating red meat, buying fewer consumer goods then the longer term gains of the health co-benefits will not be able to compensate for their immediate short term losses.
  • Are more sensitive to short term costs than long term costs, so again giving up the car is a more sensitive issue, and more salient, than flood damage 30 years from now.
  • Will privilege certainty over uncertainty. Scientists do not talk the language of certainty, and this is ruthlessly exploited by those with a vested interest in the status quo.

However, George Marshall argues that people will willingly shoulder a burden  – even one that requires short term sacrifice against uncertain long term threats – provided they share a common purpose and are rewarded with a greater sense of social belonging.

This provides a glimmer of hope especially for the  nursing commitment to climate change. Nurses often come into the profession with a purpose, a ‘shared humanitarian ethos of care’ rather than an extrinsic motivation based on money and consumer durables. How we create a greater sense of social belonging requires that we overty combat the atomistic, fragmented and individualistic culture based on the idea that “there is no such thing as society“.

 

Marshall G (2014) Don’t even think about it: Why our brains are wired to ignore climate change. Bloosmbury. New York

How to do thinking in Nursing?

The picture above is the colorado river cutting its way through the rocks on its way down to the Grand Canyon.

Nursing and ‘On Intellectual Craftsmanship’ (C. Wright Mills 1959)

‘Doing’ professional registered nursing involves ‘hands on’ practical skills, but it also involves ‘thinking’. If there is no thinking then nursing has been reduced to a ‘procedure’, a sequence of ‘hands on’ practical skills which requires training rather than higher education and which can then be undertaken by care assistants. The thinking required is not just the recollection of facts to be applied to a patient situation. For example knowing what a drug does, what the correct dose is, and whether it is right for the patient, is a recollection of factual information. The mere collection of thousands of ‘facts’ in your head to be applied to patient care, reduces registered nursing, again, to a procedure, albeit complicated by the sheer number of facts. In a rapidly changing world of demographic changes, new technological developments, environmental damages, shifting health care delivery systems, geo-political conflicts and global socio-economic challenges, what is required is critical thinking supported by scholarship. The professional nurse with a higher education preparation will, or ought to be, engaged in critical thinking to move beyond merely recalling facts as we cannot insulate ourselves from the social and political contexts in which we work.

How do we do this? Sociologist C Wright Mills in 1959 clearly called for scholarship and criticised some sociologists at that time for not doing this. In the appendix to ‘The Sociological Imagination’ Wright Mills outlines his view on ‘doing’ social science in which he suggests that ‘Scholarship’ (“scholarship is writing”) is more important for the social, as opposed to the ‘natural’ scientist, than empirical research. If nursing is as much a social science based practice discipline as one that is also rooted in the biomedical sciences, then this argument applies.

Wright Mills referred to empirical science as the “mere sorting out of facts and disagreements about facts”. I would argue that this equally applies to professional nursing (Goodman 2011). Student nurses study evidence based practice and the application of research to practice. A good deal of this is factual information based upon empirical research . Students will, however, we required to critique this research. This will involve studying ‘rules of method’, i.e. how do we ‘do’ research, but arguments on this, e.g. is an interview better than a survey to help us answer this research question, are just so much navel gazing which Wright Mills wished to avoid if he could possibly do so, as he argued:

“Now I do not like to do empirical work if I can possibly avoid it” (p205).

Wright Mills was clear on this. He argued that the task of social science and I would add professional nursing is thus to critically engage in the real world, joining the nurse’s personal experience and intellectual life through critical reflective reason as the

“advance guard in any field of learning” (p205).

Empirical ResearchA central concept in modern science and the scientific method is that all evidence must be empirical, or empirically based, that is, dependent on evidence that is observable by the senses. The term refers to the use of working hypotheses that are testable using observation or experiment. In this sense of the word, scientific statements are subject to, and derived from, our experiences or observations. Crudely, this means we need to be able to measure things, we need to be able to see, touch, hear…..

 

Wright Mills in arguing for craftsmanship in intellectual life implicitly acknowledges in the ‘Sociological Imagination’, the need to go beyond simple empirical knowledge in forming policy action when he asks social scientists in their political and intellectual tasks to clarify the contemporary causes of uneasiness and indifference (p13) to personal troubles and public issues.

The personal trouble of lying in soiled sheets in a hospital ward has to be linked to the public issue of the provision of care for older people in acute hospitals. This issue and our indifference to it, or our unease with it, has to be critically examined to seek answers beyond simply blaming uncaring individuals.

The social scientist is not to merely describe the contemporary elements of social life but to engage with it. The nursing ‘scientist’ is not to merely describe contemporary elements of patients’ experiences, e.g. abusive care, but to engage with it. Professional nurses charged with delivering care are thus asked to engage in critically understanding the social, political and economic structures in which care occurs.

Craftsmanship

Wright Mills uses the word ‘craftsmanship’. The use of the word ‘craft’ appears here to differentiate the activity from that of mere mastery of elaborate discussions about research method and which would quickly make one “impatient and weary” (p195). A craft suggests development of skill by diligent constant practice, honing one’s technique by reference to finished products and products in the process of being created to evaluate their flaws and strengths and then adjust accordingly. This is reflexive practice in that the work as it continues is being constantly worked and reworked as required. It suggests leaps of imagination and intuitive thinking and practice in the creation of a project. It calls for a departure from strict adherence to a rigid structure of routines, methods and frameworks. It also suggests a measure of artistry in thinking. In other words a potter ‘crafts’ his pot, as the clay spins there is a constant feedback to the craftsmanship of what is happening, he or she constantly adjusts the application of skill to fashion what they want. Some of this is under conscious control, some of it is unconscious based on years of experience and input. Likewise, thinking and scholarship can be a craft in this manner. The end product is not a pot but a theory, an argument, a series of questions, an hypothesis. In fact there may not be an end product as thinking may be continuous.

The scholarly craftsman is his or her work as their craft develops alongside who they are. Scholarly craftsmanship then is a state of being not only doing:

“Scholarship is a choice of how to live as well as a choice of career” (p196).

When Wright Mills wrote that:

“admirable thinkers…do not split their work from their lives” (p195)

…he preconceives notions of lifelong learning that are to follow.

Nursing practice if it were to take this concept on board may then have to consider a break away from a wage based employee model where a nurse works for 37.5 hours per week to a salaried professional/intellectual model whereupon the nurse would continue to critically reflect on issues pertinent to speciality and patient group outside of NHS contracted hours. Given the current context of the NHS and clinical practice this seems highly unlikely for clinically based nurses. But if not them, who? If not now, when? If not here, where?

To undertake this craft he asks students and social scientists to keep a journal to enable the development of the intellectual life, of the craftsmanship of social science. This should consist of ideas, personal notes, excerpts from books, bibliographical items and outlines of projects. He suggests that journals should record ‘fringe thoughts’, snatches of conversation and even dreams. This will also include the taking of copious notes from books and this needs developing into a habit.

Since Wright Mills outlined notes on journal keeping there has been the explosion onto the scene of information technologies, elearning and web 2.0. These are now new tools that were unavailable to Wright Mills. However the essential nature of scholarly activity should not be lost in any infatuation with new technologies, rather these gateway technologies could facilitate critical enquiry and journal keeping.

Wright Mills’ work thus calls for the development of scholarship as a core intellectual activity. However, critical scholarship within nursing is under threat both in practice and in Universities, skewed as it is towards empirical enquiries and buckling under the weight of bureaucracy, managerialism and the demands of the corporate University. There is an urgent need to rediscover it if we are to address the complex questions and serious issues of our age such as inequalities in health, care of frail older people, health service funding, diabetes, obesity and cardiovascular disease, depression, anxiety, the social and political determinants of health and climate change. Nurses can choose to engage with this agenda or not.

 

 

 

 

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