Action Nursing? Addressing politics and ideology?

I read this http://www.cost-ofliving.net/a-case-for-action-sociology/ a while ago, and I published this on the one dimensional state of UK nurse education, http://www.nurseeducationtoday.com/article/S0260-6917(11)00135-3/abstract back in 2011. Graham Scambler’s outline of an action sociology (AS) made me think about an ‘action’ nursing. To use/paraphrase Graham:

 So what might action sociology/nursing deliver? It has a number of discernible properties:

It is intrinsic to the sociological/nursing project: in any era sociologists will find themselves contesting ideologies (that is, erroneous worldviews or theories that sanction or provide cover for financial, business or political interests). Sociology’s very rationale is to oppose forces that suppress truths about the societies we inhabit: pace Habermas, it is necessarily oriented to justice and solidarity. It is active not passive: it lives or dies as a form of intervention against – Habermas again – ‘distorted communication’.

Nursing similarly has an ethical dimension to it, to confront the same forces, and to fulfil its role in public health at individual, community and population levels. This has never been developed fully in Nursing theory because the discipline has been focused on other laudable aims. The result is a large number of workers in the NHS have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people.

‘AS’ therefore contests the ‘taming’ of sociology in the post-1970s neo-liberal era, including a shying away from contentious or ‘risky’ issues.

This taming has certainly occurred in Nursing as it is largely bereft of critique.

Sociology’s focus is the study and theorizing of what Comte called society’s ‘statics’ and ‘dynamics’ in general, and of collective action to accomplish change in particular. This encompasses recruitment, context, and the dialectics of framing and implementing strategies. Same goes for Nursing?

Sociology’s brief extends to forays into Giddens’ ‘utopianrealism’, involving the mapping of alternative futures. This may well involve challenging or superceding the discourses or narratives for change on offer at any given time. An example of utopian realism would be a model for an NHS beyond the truly iniquitous Health and Social Care Act. There is a lack of positing alternative futures by nurse scholars that is leaving the field to others.

Scambler argues: “The Health and Social Care Act, designed to re-commodify health care in England, will accentuate health inequality.  It is a paradigmatic example of policy-based evidence. The data do not speak loud enough for elite politicians, let alone their financial and business masters, to bend their ears in fear of a crisis of legitimation. So how to remove from the statute book an Act inimical to the wellbeing of most citizens?  An action sociology cannot shrug its shoulders. It has to dwell on and exploitation and oppression. It is the actions of the wealthy and powerful that condemn those in low-income households to suffer more than their share not only of long-term but of acute illness and to die prematurely, as the likes of Engels and Virschow who charged rulers with ‘murder’ recognized in the 19th century. And health inequalities afford but an illustration here: we could have pinpointed welfare as a whole, education, housing and so on with the self-same consequences. Action sociology offers resistance to ‘formal’ democracy in the name of ‘substantive’ democracy. It underwrites ‘effective’ as opposed to symbolic resistance”.

 

This aspect (e.g. health inequalities, social determinants of health, ecological pubic health) of action sociology surely should resonate with nurses? We have been interested in how the social sciences inform nursing education and practice, well this is one way. What we do not have perhaps is a journal which is read by nurses which will focus on critical theorising and exploration of the context of nursing practice. The Sociology of Health and Illness often does a sterling job but do you think there is a gap here? if so how might we go about filling it? My very small sphere of influence is nurse education and arguing for a more fully rounded curriculum, so I’m feeling my way forward for an ‘action nursing’. Thoughts? Of course I almost blush at such a ‘radical’ action is suggesting a ‘journal’, the anthropologist David Graeber at the LSE (http://www.thewhitereview.org/interviews/interview-with-david-graeber/), or of course C Wright Mills,  might laugh at such a ‘bold’ move.

Transformation for health and sustainability: “consumption is killing us”

Transformation for health and sustainability: “consumption is killing us”

 

“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” (Loy 1988 p 302).

 

To explain why this may be so I will be addressing nonduality/dualism (Loy 1988) and anthropocentrism in order to argue that our future health and welfare is under grave threat from our particularized thinking. This will be done within the overall argument that current lifestyles in advanced industrial societies are unsustainable in the long term because they are based on certain perspectives , economic ideology and ‘one dimensional’ thinking (Marcuse 1964, Goodman 2011). In addition, if we wish to see health and welfare continue to increase across the globe, we will need an overhaul of our philosophies that underpin current assumptions about what the ‘good life’ is, and question whether current assumptions are sustainable. ‘Consumption’ has lead the UK into an economic impasse that will have serious health and social welfare consequences. This is because it based on the manufacture of demand (Harms and Kellner 2011), planned obsolescence (Fishman et al 1993), a linear model of ‘take-make-waste’ (Stubbs 2008) and fashion which all underpin the economy’s need for the drive for buying ‘stuff’. The current focus on the public debt as a cause of our economic woes is in fact a chimera, temporary and a distraction and not the real cause of our global malaise which predates the 2008 crash. Our requiem (Hamilton 2010) was being written long before the bursting of the financial bubble. While other countries enjoy GDP growth, their consumption patterns are also implicated in the impending environmental crisis. Thus, transformation of philosophy, economic models and education is required as business as usual assumptions have served ‘us’ poorly.

 

David Loy (1988 p140) argues when contrasting Eastern traditions (nondualist) with mainly Western (Cartesian) dualism “….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”. 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 reality as experienced in advanced industrial societies especially of the West, there is a dominant mode of discourse and experience which are based on various traditions of Western thought. In Cartesian dualism, the Platonic tradition and the Judeo-Christian religious tradition, the self is understood to be the source of awareness and therefore of all meaning and value. This ontological position of our ‘being’ in the world may devalue the physical world and nature merely into domains in which the self fulfills itself. The subject is separate from object. The human subject becomes capable of confronting the objective world, a word of controllable facts. 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, the father of modern empiricism who argued in 1620 “The world is made for man, not man for the world” . In his essay ‘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. Barton Perry (2011) adds in his analysis of Bacon’s views on nature“Observe nature in order that you may use nature, thus converting it into the habitation, instrument, and treasure of man. Here is the supreme maxim of our modern world, and the chief ground of its peculiar confidence and hopefulness”. This has echoes in Sigmund Freud’s (1992 p197 orig. 1927) assertion: ‘The principal task of civilization, its actual raison d’etre, is to defend us against nature’.

 

The call to have dominion over, conquer, harness, control or subjugate nature is predicated upon this idea of separateness from it, it is dualist in origin: (human) self v (nature) other. 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) suggests 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.

 

This view of a separate self supports a world view that places this self at the centre of the search for truth and the at the centre of the universe, it is anthropocentric (Foreman 1991). The anthropocentric viewpoint of ‘us’ means humanity apart from nature, we are the central and most significant entities in the universe, we assess reality through an exclusively human perspective.

 

It is arguably the case that the anthropocentric view dominates in Western thought, making us incapable of making the interconnections between the stars, the external cosmos of the myriad galaxies, the internal human physiological cosmos, the ecosphere, the biosphere, and ourselves. We then delude ourselves when we think that we are separate entities, that we are able to control for our own benefit that which we are actually a part of. Thus we have triumphed over nature controlling it for our own ends resulting in the magnificence of cities such as New York, which have become our own natural habitat. This comes at a cost. We are unable to see systemically, inter-connectedly or interdependently. The separation between humanity and ecosphere is complete within consumer capitalism in its delivery of the dreams of avarice. If however we can see nondualistically then humanity is the natural world and so what we do to it we do to ourselves. In consuming nature we consumes ourselves.

 

Consumption per se is not the issue, it is the form it takes within a particular structure of social meaning and which took on a new and very powerful form during the industrial revolution: The separation of man from nature allied to empiricism, science (Shabecoff 2001) and technical rationality (Marcuse 1964). Today, this leads to an inability to link the meaning of the use of oil as a natural and finite resource and oil as human artifact which is now embedded into our socio-political culture. Since the 1980’s a new economic creed was grafted onto this toxic stump of dualist thinking: neo-liberal economics (Shah 2010) in which free market ideology has made us servants of the economy and not its masters. The economy has become reified, as if it has a life of its own, as if we have forgotten that it is a human edifice with no concrete existence, that it can be torn down and refashioned, we have accepted a lie…that there is no alternative.

 

It took little time for the discoveries of science in partnership with extractive and manufacturing industries to raise the living standards and hence improve greatly the health of certain populations. There were genocidal casualties of colonial development, but for an increasing number of people on the planet ‘we have never had it so good’. The struggle for the pacification of existence (Marcuse 1964) has been turned into the struggle of the policing of resistance. Many no longer can resist the lures of new forms of social control that anaesthetises our critical faculties so that we are unable to posit alternatives to the current hegemony of consumer capitalism which includes it’s Chinese, Russian and Indian forms. Citizens are no longer citizens, we are primarily consumers of goods and services many of which are unnecessary, silly or just downright dangerous. Our political discourse becomes debased and is riven with debates about how best to manage consumer capitalism rather than posit any real alternative.

 

Our rapacious appetites results in the forced extraction and despoilment of the environment for oil, water, minerals and rare earth elements, and other environmental goods. The result is ocean acidification, water shortages, over fishing, oil wars and toxic chemical and nuclear dumps.

In subjugating nature, in controlling industrial processes, with the literally, earth shattering successes of nuclear technology and scientific achievements, we have created a brave new world fit for….buying stuff. Francis Fukuyama (1992) stated that we are at ‘the end of history’, free from ideological struggle, free….to buy stuff. Workers of the world may have united to lose their chains but they are now free to…buy stuff. In advanced industrial countries most of us are comfortable. Beveridge’s social evils of want, disease, ignorance squalor and idleness largely quelled, quelled so that we may…buy more stuff. The banks bring nations to their knees following a binge on cheap credit, financial sleight of hand, consumer debt and a housing bubble…and now to get out of recession we are exhorted to…buy even more stuff. Consumer confidence is the holy grail of discredited economic gurus whose pseudoscientific neo-liberal pontifications are as worthless as sex education to the whore of Babylon. The twin towers fall, so shocking the President that he exhorted Americans to ….go and buy stuff (Spiers 2003). We’ll counter the backward desert savages with shopping…..Prada versus prayer, Louis Vuitton versus Vengeance and Dior against Death.

 

Ferguson (2011) asks how western civilization came to dominate the world from humble beginnings in the 15th century. He argues that the West developed ‘6 killer apps’: competition, science, democracy, medicine and the protestant work ethic and consumerism. So there we have it the apogee of civilization includes our right to buy.

 

Spencer Wells (2010) argues that our culture has now reached a point where we must reevaluate our relationship to nature and consumption in order to survive. He argues that when we became farmers instead of hunter gathers we set in train new modes of social relationships. As populations expanded there was a need to apportion limited resources such as water, this results in social hierarchies and inequalities. Growing grain had many benefits but results now in a more crowded planet with populations that have become more sedentary and unhealthy.

 

Ben Ami (2010) tells us however that growth is good, consumption is good and we could have ‘Ferraris for all’. He argues that in advanced industrial societies we have seen decreases in infant and maternal mortality rates and increasing life expectancy coupled with control of infections. We live longer healthier lives. Hans Rosling in his online gapminder series also points out that these indicators are also rising in many developing countries, but he warns that success may literally cost the earth. So how can consumption be killing us?

 

Well, it isn’t. Goklany (2006) argues that economic growth, technological change and free trade has helped to power a “cycle of progress” that in the last two centuries enabled unprecedented improvements in every objective measurement of human well-being. Poverty, hunger, malnutrition, child labor, illiteracy and unsafe water have ceased to be global norms; infant mortality has never been lower; and we live longer and healthier lives. Further, Goklany’s research suggests that global agricultural productivity is up, food prices are down, hunger and malnutrition have dropped worldwide, public health has improved, mortality rates are down, and life expectancies are up. So that its then, we are fine.

 

Except that since he wrote that in 2006 the world saw one food crisis in 2008 and this year 2011 the UN’s Food and Agriculture Organisation are giving the global food market ‘critical’ status, again. The Millennium Development Goals have still to be met and maternal and infant mortality is still at numbers too high in many countries to enable any level of complacency.

However, if you view the world anthropocentrically within the frame of reference of consumer capitalism and you happen to live in advanced industrial nations in wealthy suburbs. You can even muster hard empirical evidence to show the beneficence of the global economic system.

 

The problem with this viewpoint is time frame. Seen from the last 200 years enormous, unprecedented progress has without doubt been made. However the time frame for a proper assessment of the current global system is much longer than that. Even in human time frames the last 200 years is a very short period of history. Depending on definition, the Roman Empire lasted over 400 years, and from the steps of the senate, Julius Ceaser may have dreamed of a millennium of Roman domination. World history is littered with the ruins of human civilizations, hubris comes before a fall. We are not Rome or Byzantium. We have controlled the natural environment (up to a point) to produce food and shelter for billions. However there is a poverty of spirit, a neglect of the ‘bottom billion’, willful ignorance of the casualties of inequalities based capitalism, a disconnect from environmental destruction and a lack of vision of alternatives that may lead to more healthy, sustainable lives on a finite planet as we bump up against limits.

 

Of course, assertions about limits needs some evidence. A key paper in this respect is that which addresses the issue of planetary boundaries – i.e. that there are limits to what we can achieve on this planet, that we need urgently to identify what these limits are and then to address what socio-economic conditions would allow all of humanity to live within the planet boundaries. If we do not do this, the argument runs, then the ecosystem services upon which all of us (the biosphere) may well collapse leading to a cull of humanity inline with the extinctions we are already exacting on the living world right now. Rockstrom et al (2009) have tried to identify what the key boundaries are and what the limits are within each. They suggest that humanity has already transgressed three of nine boundaries:

 

  1. CO2 emissions for climate change.
  2. Biodiversity loss.
  3. Biochemical boundaries – the nitrogen cycle (the phosphorous cycle has not yet been transgressed)

The other boundaries discussed include:

  1. Ocean acidification
  2. Stratospheric ozone depletion
  3. Global fresh water use
  4. Change in land use
  5. Atmospheric aerosol loading (not yet quantified).
  6. Chemical pollution (not yet quantified).

They also argue:

In the last 200 years, humanity has transitioned into a new geological era—termed the Anthropocene—which is defined by an accelerating departure from the stable environmental conditions of the past 12,000 years into a new, unknown state of Earth”.

 

In order to maintain a global environment that is conducive for human development and well-being, we must define and respect planetary boundaries that delineate a “safe operating space” for humanity. We must return to the long-term stable global environment that nurtured human development”.

 

Consumption may be killing us in more prosaic ways. The Roberts and Edwards (2010) thesis in The Energy Glut is that fossil fuels are making whole populations fat. We have replaced food with fossil fuels as our main energy source, while at the same time they argue we are eating less than we did, and certainly no more. We have become sedentary, replacing walking and cycling (active transport) with mechanical modes of transport mainly the motor car. Whole societies are using the energy oil has given us to replace physical labour. The upside is the construction of advanced civilizations and huge increases in food production, and the ability to buy stuff, the downside is that as countries develop populations get fat, more get obese and we contribute to climate change.

 

There is also the argument for a poverty of spirit leading to poor mental health fuelled by ideas such as ‘Affluenza’ (see both books of that name by Oliver James and Clive Hamilton and Richard Denniss).

 

Transformation

 

My frame of reference is that healthy lives depend on a healthy socio-economic and physical environment as outlined in the Social Determinants of Health approach (Dahlgren and whitehead) which has as its outer layer in the model ‘general socioeconomic, cultural and environmental factors’, i.e. social and environmental structures. Thus, I largely agree with Peter Morrall (2009) who argues that patterns of illness and disease are largely determined by issues of social structure and increasingly physical environments. Social structures protect some while damning others to misery and poverty as evidenced in the inequalities in health literature. The affluent even in poor countries and difficult environmental conditions live in ‘safe’ enclaves where they can ensure clean water and a ready supply of food, even in famine stricken countries, money buys food. However, even the affluent will be affected by global changes in certain key environmental limits.

 

Social structure results from a dialectic relationship between objective ‘social facts’ and subjective ‘social action’ which occur within distinct forms of power relationships. The key power relationships operating at present is the hegemonic stranglehold of advanced consumer capitalism in which a very small percentage of the world’s population own the majority of the world’s wealth and enjoy its income. Many do not understand or recognise the notions of limits, while others put undue faith on the resourcefulness of humanity to solve the problems but to do so within the frame of reference of ‘business as usual’ unaware that their selves are interconnected and interdependent within a much wider framework of meaning.

 

Thus there is a need to transform thinking. Currently education is the problem not the solution. David Orr (2004) argues that we are educating graduates to be clever not intelligent, and this applies in many if not all disciplines. Cleverness built the atomic bomb, intelligence questions our need for it. Cleverness invented credit default swaps, intelligence called for financial regulation. Cleverness develops markets for things we don’t need, spends money we have not got and distracts us with bright shiny things. Intelligence understands bread and circuses.

 

To encourage and transform thinking there is a need to engage in provocative pedagogy whereby students engage in intellectual critique through being challenged with provocative positions.   They need a sociological imagination to connect their personal troubles with public issues, to fully understand their personal biographies as related to wider social forces at this point in history.

 

Thinking in private without action is in Panton’s phrase merely ‘mental masturbation’ (Panton 2003). Marx (1848) once wrote that philosophers have sought to understand the world, the point however is to change it. So transformative education is critical, provocative and challenging leading to some form of moral action based on a deeper understanding of the human and biosphere condition. This is what Universities are for. However, Peter Morrall (2009b) suggests that Universities in many subjects are losing this vision. They are becoming ‘training warehouses’ bogged down by managerialism, bureaucracy, commodification and consumerism. Education is being increasingly defined and seen as a commodity to be bought, whose only useful purpose is to lead the purchaser into paid employment, whose worth is judged by its ability to do just that.

 

Students in this view are becoming dulled by an all encompassing ideology which narrows the focus on careers and higher pay. Universities may become ‘educational’ establishments focused on providing work skills and applied knowledge. Worthy as this is (and of course is professionally necessary) but without critical enquiry and the ‘search for truth’ there is little point to the university.

 

Medical and nursing disciplines cannot be immune from this process. It is not enough to learn how the body works and what to do when it goes wrong. This is navel gazing of the worse kind. Many doctors and nurses have for a long time been pioneers for social action, acting on behalf of the poor, weak and vulnerable. That is their ethic. That has been their historic mission, the problems of this messy little world may not mean a hill of beans to many but without a reawakening of consciousness and a reconnection of self to others, which includes the biophere, the future looks grim. Peter Morrall has argued that we as health professionals and/or academics have an ethical responsibility to take individual, collegiate, and organisational action with regard to the social ills which affect human health and happiness.

 

However, taking a stand is hard. Ethics is hard. Ethics requires thinking. We may be the only sentient being on the planet who can think and reflect on our existence and the search for ‘truth’ It may be that we have a special responsibility to think about our decisions and why we make them. Damon Horowitz has recently argued (2011) “ Not only can we think, we must. Hannah Arendt said, “The sad truth is that most evil done in this world is not done by people who choose to be evil. It arises from not thinking.” That’s what she called the “banality of evil.” And the response to that is that we demand the exercise of thinking from every sane person

 

It requires some moral framework to guide that thinking, we are required to think about the human condition and the consequences of our actions. John Kenneth Galbraith said that ‘communities are too comfortable to care’, while John Stuart Mill argued “It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied”. Affluence, satisfaction, happiness and over consumption can dull thinking and harden our sensibilities to suffering. Provoking dissatisfaction may not produce more happiness but it may encourage an exploration of eudaemonia.

 

Conclusion

Evidence is mounting that current consumption patterns are costing the earth, the result is a paradox and whether you think this is a good thing may depend on what values you hold and what indices you choose to look at. So at one level this is about values at another there is an empirical question regardless of whether you like or value consumer society or not. The question is will empirical reality overwhelm us and confer our squabbles about resources to the dustbin of history?

 

We have 4 options (Elliot 2011):

 

  1. Do nothing because advanced industrial capitalism is robust and self correcting, we have plenty of oil and climate change is a fantasy.
  2. Argue that there is an incompatibility between sustainability and current economics. However alternatives to globalization are not well worked out and would not attract popular support (yet?).
  3. Bring human ingenuity to bear on the problems, invest in green technologies, develop global governance and change our relationship to the biosphere.
  4. File it all under ‘too difficult’ and hope it is not too late to respond when the crisis breaks.

If you choose not to decide you still have made a choice, my guess is that we will do 1 and 4.

 

Benny Goodman 2011