The ‘will of the people’ is a chimera.

Photo by davide ragusa on Unsplash

“The term chimera has come to describe anything composed of very disparate parts, or perceived as wildly imaginative, implausible, or dazzling.”

“The people have spoken” and we must respect the “will of the people”. So goes the mantra. It adds that democracy itself is undermined if “the will of the people” is not followed through. And how is this “will of the people” expressed? Through a simple majority vote in a plebiscite in which a complex issue having long term serious consequences was reduced to a simple binary choice.

In political philosophy, the general will (French: volonté générale) is the ‘will of the people as a whole’ The term was made famous by 18th-century French philosopher Jean-Jacques Rousseau:

“The law is the expression of the general will. All citizens have the right to contribute personally, or through their representatives, to its formation. It must be the same for all, whether it protects or punishes. All citizens, being equal in its eyes, are equally admissible to all public dignities, positions, and employments, according to their capacities, and without any other distinction than that of their virtues and their talents.” Article Six of the Declaration of the Rights of Man and the Citizen (French: Déclaration des droits de l’Homme et du citoyen), composed in 1789 during the French Revolution.

I’m arguing that there is an unbreachable gap between the Theory and its Practice, and that it’s theory is undermined by the lack of analysis of ‘power’ in modern (finance, rentier) capitalist societies, for there never can be equality while capitalism endures. Equality before the law, and equality of representation, as an expression of the ‘general will’, is an ambition that is forever thwarted. For many this is a good thing anyway.

Rousseau sets out a laudable Enlightenment aim regarding the equality of citizens before the state but its practice becomes a bourgeois justification for obfuscation of the nature of power, capital accumulation and exploitation.

By ‘Bourgeois’,  I mean a sociologically defined class, and for simplification, I’m referring to people (and their apologists) with a certain social, cultural and financial capital belonging to an affluent and often opulent stratum of the ‘middle class’ but more correctly are the capitalist class, who stand opposite the working class. Jacob Rees Mogg, although an aristocrat, exemplifies the high end of the bourgeoisie. Other prominent members would include Richard Branson, Nigel Farage, Theresa May, Tony Blair, David Cameron. Even Royalty has been reduced to being bourgeois ‘as image’ (‘Kate and Wills’ for fucks sake) in a deliberate attempt to make them look more ‘normal’ and thus acceptable in austere times.

Who are ‘the people’ ? Bourgeois theory reduces everyone to an undefined abstract mass in which there is a right to equality, an equality however that has been so eviscerated of any force that it has been reduced to meaning only the freedom of expression via the ballot box. ‘One person, one Vote’.  In reality it is ‘political franchise’ equality, not an economic one, or a social one, or a legal one. However these other aspects of ‘the people’s’ equality, cannot be disaggregated except abstractly. The reality of social life is that this bourgeois undifferentiated mass is in fact riven with divisions of class, gender, ethnicity, religion, region and identities with the result that there is inequality, and inequity, of opportunity, outcome and resources. There is a lack of fairness, freedom or justice in many areas of social and political life.

There is no ‘the people’.

There is (bourgeois) Capital and Labour, and within those two categories there are further divisions.

Parliament has been captured by the bourgeoisie and cannot express any collective will. There is no ‘collective will’. There is ideology wrapped up in the glitter of democracy.

Capital: There are powerful actors with so much finance, social, and cultural capital (Pierre Bourdieu) that they can buy power (Graham Scambler’s ‘Greedy Bastards Hypothesis) and bypass Rousseau’s entreaty for equality. “Men of wealth buy men of power”. And yes, it is usually white men in the U.K. If you doubt the power of capital to fashion society, culture and economy you’ve swallowed bourgeois ideology propagated through mass media of communication, for example via Murdoch’s empire. Read up on the Koch brothers in the US, or the actions of wealthy landowners in the UK. Read Guy Debord’s ‘Society of the Spectacle’, or Foucault in ‘Archeaology of Knowledge’ or Antonio Gramsci on Hegemony, or Marcuse in ‘One Dimensional Man’ …or the rest of the work of the Frankfurt School. Let’s not of course forget the works of feminists as such as Simone de Beauvoir or huge literature of post colonialist critique.

If there is no ‘people’ then there can be be no ‘will’. If powerful groups of bourgeois actors can use money, power, influence to direct citizens into acceptable (to bourgeois ) modes of thinking then notions of ‘will’ are diluted. Whose will is being expressed here?

Further, on the EU: Bourgeois thinking is divided itself, resulting in the spectacle of bourgeois actors lying to each other safe in the knowledge that their power base and wealth is not being challenged, just the surface form of political organisation. The UK is a thouroughly bourgeois country either in or out of the EU. Men of wealth will not affected to the same degree as ordinary citizens whose lives will be made or broken by bourgeois decision making.

The law in practice does not represent General Will, it represents the outcome of the battle of powerful bourgeois actors and their battle with ‘the proletariat’. The EU referendum result expressed that ideological battle within the ranks of the bourgeoisie, in which some resorted to dangerous populism, lies, fears and deflection. It was as legitimate an expression of ‘general will’ as the Prince of Wales’ wank stain is to a claim to the throne. They are playing a dangerous game in which some forces of white proletarian dissatisfaction with elites is being channeled toward ethnic groups. This so called ‘will’ is being distorted towards racism if not fascism.

Finally, simple majority voting can be tyrannical, and more so if complex issues are reduced to overly simplistic binaries of leave/remain.

 

 

The Task….

It is the political task of the social scientist — as of any liberal educator — continually to translate personal troubles into public issues, and public issues into the terms of their human meaning for a variety of individuals”.

C Wright Mills. The Sociological Imagination (1959).

This statement is the reason for a good deal of my work. I was first introduced to the book ‘The Sociological Imagination’ way back in 1983 when it was the very first text given to us undergraduates. I admit the full force of the book’s meaning was understood only later and after reading various sociological theories and research studies did this ‘quality of mind‘ begin to flourish.

The sociological imagination enables us to grasp history and biography and the relations between the two within society. That is its task and its promise

In everyday conversations, and on social media, we speak about any manner of things that excite us, annoy us, amuse us. We complain and comment. All too often however we do not engage in the ‘quality of mind’ that is the sociological imagination and thus we fail to fully understand the issue. This does not matter for the trivial issues, but it does for wider social and political issues. Our lack of critical understanding, our lack of an historical context , our lack of imagination, leads all too often to views and actions that are stupid, racist, dangerous and callous. In so called democratic societies we end up voting for stupid, racist, dangerous and callous political leaders.

At best, this lack of an imagination leads to policy that is woefully lacking. In a previous post I outlined the complex and multifarious nature of the obesogenic environment.

Those struggling with weight gain are all too familiar with the stigma that follows overly simplistic explanations and policy makers are all too readily drawn to lifestyle drift response to weight gain.  Lifestyle drift refers to the phenomenon whereby policy makers accept that there are wider determinants to health issues such as weight gain, but drift towards lifestyle responses as the key interventions. This results in the insanity of accepting the ‘obesogenic environment’ but then advocating individual behaviour change as the policy response.

It is necessary for me and others like me to point out that your personal trouble is to be understood not only, or just, as a result of your personal decision making. It is to show that your personal decision making occurs in a society in which there are powerful individuals, organisations, corporations, technologies and social structures who have a vested interest in the decisions you make, and who then collectively spend billions in product development, marketing with ‘sign values‘, demand management, and dissatisfaction manufacturing to make a profit. Claims of ‘corporate social responsibility‘, or ‘creating shared value‘, have to be taken with huge truck loads of salt in far too many examples.

The sociological imagination links your individual decision to drink coca cola with the vast network that lies behind the point of delivery of that can into your hands. Your ‘personal biography’ which includes “I drink coca cola” is linked to this point in history in which there exists a multi billion dollar corporation with a vested interest in you drinking its product. The sociological imagination takes this relationship between can and corporation and investigates what this means. It does not say “Thou shalt not drink coca cola”. It does however provide information about what that simple act means socially and politically so that we come to see drinking a can of coke as a social and political act as well as a thirst quenching one.

The Sociological Imagination

“The sociological imagination enables us to grasp history and biography and the relations between the two within society. That is its task and its promise” C. Wright Mills

Photo by Lance Anderson on Unsplash

This is a key work in the sociological literature and provides a way of thinking about our experiences as individuals in society at any given point in time. The argument is that to fully understand ourselves we have to apply the ‘sociological imagination’ to our ‘personal troubles’.

The relevance for health is that this takes us beyond making overly simplistic analysis of our health behaviours, experiences and decisions. If our analysis is too simplistic then we come up partial answers to health care issues at best and irrelevant, judgemental or dangerous answers at worst.

C Wright Mills wrote:

‘…men (sic) do not usually define the troubles they endure in terms of historical change…’ (p3).

So, what is a ‘trouble’?  That might be an episode of illness.

 

 

Personal troubles:

 

  • Having type 2 diabetes and thus having to manage that condition
  • Living alone
  • Being overweight
  • Worries about changes in the benefits system

 

 

We may not consider that our issues (as personal troubles) are better or more fully understood as being linked to living in the 21st century, or that the roots may lie in current society. We are

‘…seldom aware of the intricate connection between the patterns of their own lives and the course of world history.’ (p4).

We do not

‘…possess the quality of mind essential to grasp the interplay of man and society, of biography and history…’  (p4).

In addition we:

‘…cannot cope with their personal troubles in such ways as to control the structural transformations that lie behind them.’  (p4).

What ‘structural transformations’ might be behind living alone, diabetes, weight gain and money worries?

What is a ‘structural transformation?’

If we think of society has having ‘structures’, which vary from society to society and which varies within the same society over time (history), we may begin to understand that society is but the outcome of individuals, groups, communities and populations deciding to act out their relationships one with another. In doing so they create (and are created by) society and its social ‘structures’. We have family structures, gender role structures, work organisation and employment structures, educational structures, health care delivery structures, food manufacture, marketing and delivery structures, economic structures…..  A commonly experienced social structure today is the baking or buying and eating of cake and coffee as a social event. In response to, or perhaps to encourage this, we now have both small businesses in town centres and global corporations (Nestle, Starbucks, Costa Coffee) oriented to selling us high calorie non essential  food and drink.

Relationships between people evolve as humans live their lives and develop their capacities and these relationships then act as structural patterns for others to follow. This process of ‘evolution’ and ‘pattern’ changes over time and between societies. An individual thus is both shaped by these (structural) patterns of living, and in living their lives they in turn shape the patterns (structures). Our lives are thus ‘structured’ but not determined by these structures.

What social structures are there and what are those structures that lie beneath the personal troubles outlined above?

To help answer that question Wright Mills argued that

 

what they need…is a quality of mind that will help them to use information and to develop reason in order to achieve lucid summations of what is going on in the world and of what may be happening within themselves… this quality…(is) the sociological imagination.” (p5).

 

What information do we have about Type 2 diabetes – its rate, prevalence, risk groups, epidemiology, aetiology, and the wider determinants? To fully understand why anyone now has Type 2 we need to get this information and consider for example that:

 

We might be ‘overweight’. What exactly does that mean and how much of an issue is it? The fact that we might now have type 2 diabetes suggests that previous diet, levels of exercise and lifestyle may have contributed. What do we know about weight gain and the link to diabetes?

Our personal story of being overweight is linked to various structural and technological changes in society over our lifetime. These changes include the abundance of fossil fuels to use for energy (a technological change) instead of food, so that cars replace cycling/walking. Active travel is replaced by driving, while the social meaning of driving and car ownership underpin our unwillingness to cycle, walk to the bus stop or railway station.

So, to what degree are we responsible for gaining this weight? Many of us have lived through a time when the public’s understanding of diet was perhaps rudimentary, constrained as it was by rationing and availability and the social norms that construct a ‘healthy’ diet. Many of us experienced ‘socialisation’ which involves learning the values, norms and beliefs of our culture regarding what is appropriate food. To what degree is  vegetarianism, veganism or the mediterranean diet, popular and or promoted as healthy option?

We need to consider what a healthy diet is and how the public get to know. Currently the eatwell plate is a suggestion, but to what degree do the public know about it, how much are they guided by it and what is the evidence base for it? We might want to consider if there are any vested interests in selling us high calorie, sugar dense foodstuffs?

Exercising a sociological imagination also asks what social changes occurred so that we have now an abundance of sugar in the form of high fructose corn syrup?

Our early lives would have been guided by social norms and what shops could provide, as well as cost. the ‘personal trouble’ is weight gain but it is also a public issue as the whole UK population has gained weight. So we need to connect changes in social structures and historical events to the personal story that is a diagnosis of diabetes, to fully understand current health.

The role of sugar in the diet is an issue, what is the history of the dietary advice regarding fat and sugar? We may well have been consuming sugar in amounts that seems normal and indeed is hidden. This could be part of what is called an ‘obesogenic environment’ in which we are immersed and have been for several decades. What do we believe and think about sugar in the diet? To what degree does rational thinking about the risk to weight from eating a ‘normal’ UK diet, feature in buying, cooking and meal preparation decisions?

 

The sociological imagination enables its possessor to understand the larger historical scene in terms of its meaning for the inner life….’ (p5).

This is what Wright Mills refers to when he argued that:

The first fruit of this imagination…is the idea that the individual can understand his own experience and gauge his own fate only by locating himself within his period, that he can know his own chances in life only by becoming aware of all those individuals in his circumstances’ (p5).

 

Wright Mills outlines:

‘The personal troubles of milieu and the public issues of social structure’. (p8).

Troubles:

These occur within the individual’s immediate experience and relationships. They relate to the individual self and to those areas of social life of which the individual is immediately, directly and personally aware. The description of what the trouble is and what the solutions are, come from the individual and within the scope of their ‘social milieu’. A trouble is a private matter; they are values that we feel are threatened.

One of our personal troubles may be feeling and living alone and feeling that whatever we does makes no difference (learned helplessness). The value being threatened here is the value of social relationships being missed.

 

 

Learned helplessness is a state of mind which results in the inability or the unwillingness to avoid negative experiences as a result of thinking that those experiences are unavoidable (even if they are avoidable). This arises because one has learned that one does not have control over the situation. Learned helplessness theory is the view that clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation.

 

Public Issues:   

These are matters that go beyond the local environment of the individual and their inner life. They result as an ‘organisation’ of many such situations into the structure and institutions of society. The countless individual social milieux (i.e. ‘all the lonely people’ in the UK) overlap and create society at points in history. An issue is a public matter; issues threaten values held by the public. When this happens there may be public debate about what that value is and what really threatens it. There is some evidence that loneliness is becoming a public issue as the scale of the issue becomes clearer and its health effects become known.

One of Wright Mill’s examples to explain the use of the sociological imagination is unemployment:

‘When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals’. (p9).

What the individual unemployed man (out of the 15 million) experiences is often caused by the structural changes in society. When global economics means that steel can be produced more cheaply in a foreign country (a structural change) then a UK steel works shuts down. To be aware of the idea of social structure and to use it, is to be able to trace links among a great variety of individual social milieu which, as Wright Mills’ states, ‘…is to possess the sociological imagination’ (p11).

There is more than one person who lives alone, is overweight, struggling with diabetes and has money worries. Therefore these personal troubles are also public issues of society if we use the sociological imagination.

To fully understand our life means understanding how society has changed and the opportunities and threats to health that arise as a consequence. It means understanding that our personal agency, the freedom to act, operates within particular social structures that constrain action as well as providing enablements. So, what constrains our action, what enables us to take control of our lives?

Understanding obesity using the sociological imagination links the personal trouble of weight gain with the public issue of whole population shifts in BMI within the context of the obesogenic environment. A fuller understanding of ‘fatness’ goes beyond overly simplistic calculations of calories in = calories out type equations, and simplistic exhortations to “eat less move more”.

Implications:

Health and illness is to be thought as arising from social structure as well as, if not more than, biology. The knowledge that diabetes results not just from the individual’s choice of diet, but also from the social environment, should indicate a  public health and socio-political role. Health education is not just an individually focused issue, based on a biomedical understanding. Health itself has social origins. The concept of an ‘obesogenic environment’ suggests just that.

Therefore strategies that will assist people to move towards health must take into account the social and political context in which they live. Society has to change as much as the individual. Individualised models for change that ignore this will have less chance of success.

Understanding that illness, although at first may seem self-inflicted and out of free will, may result from the social milieu of the individual.  Victim blaming of the unpopular patient, the obese, the self-harmer, the drug addict, the alcoholic, is not only poor practice but is theoretically myopic. That is to say it does not understand the wider determinants of health. This realisation should change the language around health into a more open, less judgemental stance towards the people. For example, the label alcoholic implies the trouble lies within the individual when the roots may also be social.

To summarise: 

  • Health and Illness both derive from socially structured human agency, societal as well as biology.
  • The patterns, experience and causes of health and illness has to be understood in the context of history and culture.
  • The meanings that people attach to health and illness not only are built by social structure but go towards creating social structures.
  • Professionals need to acknowledge the complexity of health and illness and adopt a more open, non judgmental viewpoint.
  • There is a social/political and public health role.
  • Models for change have to go beyond individualised biomedical understandings of health and illness, realising that ‘education’ is not a universal panacea.

 

Benny Goodman      September 2017

 

Antonio Gramsci on intellectual thought – challenging nursing.

Antonio Gramsci on intellectual thought – challenging nursing.

 

 

Antonio Gramsci (1891-1937), leader of the Italian Communist party, was arrested and imprisoned by the fascist regime in 1926 and died in the Quisisana clinic in Rome in 1937, aged 47. His pre prison work and his ‘prison notebooks’ have hugely contributed to the examination and development of political philosophy and intellectual thought. Among the ideas he developed are the role of the intellectual in culture and politics and the concept of hegemony. The prosecutor at his trial was acutely aware of his intellectual abilities, and thus threat, and stated:

 

“We must prevent this brain from functioning for twenty years.”

 

(Buttigeig 2011 p16).

 

Gramsci found himself in a concrete prison not of his own choosing. Nurses find themselves in an abstract prison of the mind put there by their own reason, their lifeworld colonised by the systematic distorted communication of the strategic action of powerful others.

 

This is all a world away from the daily work of nursing, and so at first pass may appear of interest only to the likes of critical social scientists or historians of political thought. Reading Gramsci opens up a discussion on what being an intellectual might mean and of how power is exercised and maintained. Nurses going about their clinical work will not be vexed by such questions and it might be the case that academic nurses will not be either. That could be a mistake given the current context outlined by Streek (2016) of global challenges to social order which have current and future impacts on health and health care delivery.

 

That context is variously called late modernity, post modernity, post industrial, disorganised, financial, rentier, or neoliberal capitalism. Wolfgang Streeck (2016) echoing Gramsci, suggests this context is actually a post-capitalist interregnum in which the old system is dying but a new social order cannot yet be born. Streeck calls the current order one of multi-morbidity, climate change being one of many frailties as we head towards social entropy, radical uncertainty and indeterminancy. Streeck argues that the current context is anchored in a variety of interconnected developments:

 

  1. Intensification of distributional (capital v labour) conflict due to declining growth.
  2. Rising social inequality.
  3. Vanishing macroeconomic manageability.
  4. Steadily increasing indebtedness (private and sovereign).
  5. Pumped up money supply (from quantitative easing).
  6. Possibility of another financial crisis as per 2008.
  7. The suspension of democracy.
  8. Slowdown of social progress.
  9. Rising Oligarchy and Plutocracy.
  10. Governments’ inability to limit the commodification of labour, money or nature.
  11. Omnipresence of corruption.
  12. Intensified competition in winner takes all markets.
  13. Unlimited opportunities for self enrichment (for the 1%).
  14. Erosion of public goods and infrastructure.
  15. The failure of the US to establish a stable global order.
  16. Public cynicism towards economics and politics.
  17. Rising populist nationalism and the spectre of fascism and isolationism in the US.
  18. Fracturing political blocs and alliances.
  19. Erosion of Democratic legitimacy and thus a democratic deficit.

 

 

To that:

 

  1. Health Inequalities.
  2. Potential Ecosystem collapse.
  3. Disruptive technologies: Automation, Artificial Intelligence and digitalisation.

 

 

Streeck seems to suggest that it is the very success of neoliberal capitalism, its defeat of social democracy and forces that would otherwise tame its destructive tendencies, that has paved the way for such developments that characterise its internal contradictions. There is nothing left to save capitalism from itself.

 

There are countervailing voices such as Joseph Norberg (on the possibility and actuality of progress), Daniel Ben-Ami (on growth based capitalism to solve ecological problems) and Stephen Pinker (on reducing levels of global violence) who paint more positive pictures. Add of course the voices of politicians who promise to ‘Make America Great Again’, to create “A country that works for everyone’ or establish ‘Russia as a Normal Great Power’ or to regain ‘primacy in South East Asia after a century of humiliation’. The picture now is one of complexity, tension, dynamics and unpredictability.

 

None of this bothers most UK nurses who work with individuals who are ill, distressed, living with long term conditions, or dying in hospital and at home. They are also involved in public health basing their approaches in general health management, health education and health promotion. Their training and education focuses on instrumental competency based knowledge and skill acquisition but it lacks critical enquiry into the context in which they work. Gramsci’s approach to intellectual enquiry could provide a blueprint for alternative or complementary critical nurse education that has to consider wider socio-political determinants of health, the sort of developments that Streeck outlines.

 

 

 

Gramsci’s thinking

 

We get an insight into how Gramsci’s brain functioned from a letter he wrote in 1929 to the wife of a comrade who also was in prison for ‘anti-fascist’ activity. The context is that of how to study while in prison. The prison referred to, of course, had concrete existence. However, if we consider that today nurses may imprison themselves within the conceptual walls of stultifying paradigms that block freedom of critical thought, for example biomedical empiricism, his thoughts on reflection and analysis might be useful. The letter predates Wright Mills’ 1959 chapter on intellectual craftsmanship, a reading of which shows some commonality in approach and is an alternative to the metrics used today in our research excellence framework assessments. One wonders if Gramsci was writing today, would he secure tenure in some contemporary Universities.

 

He wrote in the letter that one must abandon, in the prison context, the ‘scholastic mentality’ and banish the thought of pursuing a regular and in depth course of study. Along with Wright Mills who later wrote about avoiding empirical work if he could help it as it was merely about sorting out facts and disagreements about facts, this statement appears to be counter intuitive until one considers that a goal of intellectual life could be about criticality, understanding philosophy, self, culture, history, politics and society. Again put this way, many nurses may well eschew intellectual enquiry as irrelevant.

 

Gramsci urged language learning as rewarding, but more interestingly is his outlook on the relative paucity of texts in prison libraries. He argued that a political prisoner must extract “blood from stones” (Buttigeig 2011 p15). The paucity of books in prison was of course a function of the external constraints imposed by the regime. The ‘paucity of books’ available to students today may be a result not of external concrete constraints but of internal self imposed constraints as to what counts as proper reading for a degree in Nursing. Gramsci experienced a concrete prison of walls imposed by the fascist regime. We might experience a ‘prison of the mind’ constructed by dominant cultural ideas (hegemony) imposed by ourselves upon ourselves through the process of normative governmentality. Gramsci argued for ‘extracting blood from stones’, the stones being whatever he could get.

 

To get the most of the books available to him, often popular novels, Gramsci adopted the following viewpoint:

 

“Why is this always the most read and most published literature?”

“What needs does it satisfy?”

 

“What aspirations does it respond to?”

 

“What sentiments and views are represented in these awful books that have such broad appeal?”

 

For student nurses, these questions could be applied to many of the texts, for example the professional body’s literature, that they read to assist with the development of critical thinking. Critique could be emancipatory but in actuality reading ends up in uncritical acceptance. I’m not talking about appraising and critiquing research evidence or engaging in critical analysis of for example leadership theories in nursing. Criticality is lacking in the socio-political and power domain.

An example of the lack of such criticality is the almost universal acceptance of the UK’s Nursing and Midwifery Council’s revalidation process. The requirement is for nurses to renew their registration every three years by following the process outlined by the NMC. The surface reason for revalidation is that it ‘promotes greater professionalism among nurses and midwives and also improves the quality of care that patients receive by encouraging reflection on practice against the revised code’. If we apply Gramsci’s questions above to the texts on revalidation put out by the NMC, a possibility arises that we just might make alternative and critical analyses of just such banal statements in official publications.

 

“Why is the NMC always the most read and most published literature on professional behaviour?” Because of its statutory position as the regulator to protect the public. Because Nurse educators use it as the basis for their teaching. Because the NMC has the power to discipline nurses…..

“What needs does it satisfy?” Neophyte nurses, especially, need guidance on professional behaviour and standards and don’t have the time, or resources or educational preparation to consider this in an in depth way. NMC guidance provides the generally widely accepted standard……

 

“What aspirations does it respond to?” To keep one’s registration and to bolster one’s subject position as ‘safe practitioner’

 

“What sentiments and views are represented in these awful books that have such broad appeal?” The sentiment of nursing as ‘character based moral work’, of nurses as ‘caregivers’, as self sacrificial angels who always cope……

 

The answers to the 4 questions of course are myriad and those above are merely some examples requiring further reflection, reflexivity and criticism.

 

The lack of critique of the NMC on revalidation illustrates ‘normative governmentality’, in that nurses and midwives, and perhaps more interestingly nursing academics, have internalised certain norms, values and assumptions that prevent them from seeing anything other than the official line. This could be an example of what Furedi (2006) refers to as philistinism underpinned by instrumentalism in higher education, in which academics become educational technocrats rather than what Gramsci refers to as organic intellectuals.

 

Intellectuals are those with broad reading, vision and a concern for public issues. Graham Scambler argues intellectuals are not only engaged in the public sphere but do so around an identifiable moral or political position. A question arises about the degree nurses and midwives are, or wish to be, engaged in moral and political questions, the degree to which they can engage in communicative action free from systematic distorted communication.

 

The questioning of texts exemplifies the Gramscian notion of critical enquiry and action and allows us to consider such questions as, for example, what counts as research in contemporary nursing faculties. The answer to that is political in that it frames what nurse academics study, write about and publish, and it frames what students of nursing count as valid knowledge. If we apply those questions to the published outputs of contemporary nursing scholarship what answers would we get? For example, does a high h index always indicate intellectual rigour or criticality? Given the wider determinants of health, which include the social, political and ecological, it could be suggested that health care professionals would be aided in their understanding of health and illness, and hence what to do about it, by critical enquiry that goes beyond accepted epistemologies.

 

Nursing students have been told to be critical thinkers and many University curricula claim to foster such thought. Texts are not to be accepted at face value, and that we should examine assumptions and viewpoints of writers. This should go beyond for example appraising research literature for methodological rigour. Should we also appraise the metaparadigms and epistemological assumptions of ‘acceptable’ and ‘REFable’ nursing research? Should we ask what degree does contemporary scholarship in nursing reflect the sort of intellectual enquiry that Gramsci and Wright Mills advocate? In a world increasingly characterised by forces that threaten to disrupt stability and global order in ways that could be catastrophic to human health, are we preparing nurses to face that?

 

Gramsci died far too soon, and ‘without honour in his own country’. Whether he considered his life a failure in that fascism still held power, nonetheless he provides a template for thinking, studying and critique in difficult circumstances. He had a vision, he was an intellectual, he had a political purpose. Whether academic nurses in the 21st century find this inspiring or irrelevant may depend on what vision we have for nursing praxis for the future.

 

 

 

Buttigeig J (2011) in Gramsci A (1975) Prison Notebooks. Volume 1 Ed. Einaudi G. Columbia University Press. New York.

 

Furedi F (2006) Where have all the intellectuals gone? Confronting 21st Century Philistinism. Continuum.

 

Gramsci A. (1975) Prison Notebooks. Vos 1-3. Edited Einaudi G. Columbia University Books New York.

 

Scambler G (2013) What is an intellectual? http://www.grahamscambler.com/what-is-an-intellectual-2/

 

Streeck W (2016) The post-capitalist interregnum: the old system is dying, but a new social order cannot yet be born. Juncture 23 (2): 68-77

Manifesto

 

This manifesto calls for a social movement for political activism by nurses and other health professionals, to address inequalities in health and the social inequalities that highly structure, but do not determine, health outcomes. This action can operate at individual, clinical, organisational, national and international level.

Our aim is to respond to threats to health and socialised health service delivery from corporate, financial and political interests.

Our vision is for decreasing social and health inequalities in which the social gradient is greatly diminished.

Our goal is to create a networked social movement involving political and civic activism to bring critical understanding and action into the public sphere.

See:

A Manifesto for Action Nursing

Poverty Privilege and Health

In two of the richest nations ever to have existed on planet earth we have a separation which allows affluent whites to exist in a bubble of privilege; a bubble of privilege which survives the shooting of police, deindustrialisation, poverty, precarity and the social gradient in health. Privilege understands and sees how radical losers exploit poverty and exclusion, but does not want to address social and economic structures; privilege understands that pain and anger can be turned both inward and outward but looks for solutions in the individual and ‘security’; privilege sees the transmission of poverty and exclusion only in the personal agency of the poor themselves.

Washington Heights is a suburb of the most segregated city in America. Charles lives in a part of Milwaukee where the residents are 99% white, yet a few blocks up are black neighbourhoods where shops are boarded up, many houses have repossession notices on their front doors, and the air is one of decay and poverty. The separation of black and white in Milwaukee is replicated in big cities right across the US, and separation breeds a lack of empathy.”

“Local authorities which report the highest rates of people facing severe and multiple disadvantage are mainly in the North of England, seaside towns and certain central London boroughs”

“Women who live in the least deprived parts of Kensington & Chelsea can expect almost a quarter of a century more of good health than their female counterparts in the most deprived part of the borough. For females at birth, the number of years an individual could expect to live in good health based on current rates – known as healthy life expectancy – differed by an average of 24.6 years between the most and least deprived parts of the borough” (ONS, 2015)

…and yet politicians like to focus on a ‘moral underclass’, blaming them for their behaviour that causes poverty. Drink and drugs are key factors in this regard:

“Ian Duncan Smith, Secretary of State for Work and Pensions, shocked readers of the Daily Mail with: ‘Addicts and alcoholics cost us £10billion a year, says Duncan Smith: Blitz launched to help people with drink drug problems find work’ “. (Glen Bramley LSE Blog)

There is a very old debate about whether poor people owe their circumstances to structural economic factors or to moral/behavioural failings. Sandra Carlisle in 2001 argued that there are ‘contested explanations, shifting discourses and ambiguous policies’  for health inequalities: there is the ‘Moral Underclass’ discourse, the ‘Social Integrationist’ Discourse and the ‘Redistrubutive’ discourse. Each has its own explanation as to why there are inequalities and then what to do about them.

Since Sandra Carlisle wrote her paper, there has been a a good deal of evidence to suggest that structural/economic forces are a major factor in people’s health and illness. There is some evidence also of ‘transmitted poverty‘ due to adverse childhood experiences. The misuse of Alcohol and Illegal substances (they are all drugs) are of course correlated:

“There is a huge overlap between the offender, substance misusing and homeless populations. For example, two thirds of people using homeless services are also either in the criminal justice system or in drug treatment in the same year”.

Many people faced with adverse social situations learn to cope, or they become fatalistic,  or they cling together in supportive communities or they become activists fighting for social justice.  Some self harm, some drink to excess, some go to University and become doctors or lawyers or politicians.  They exercise their personal agency and succeed or fail within structurally determined circumstances. They succeed, despite not because of, the activities and ideology of the privileged. A few of the successful however, then refuse to provide more ladders while shouting “I did it so can you”.

The lack of empathy, the total separation of lifeworlds, arises partly from moral intuitions that both blinds many politicians and commentators to alternative explanations pf poverty and binds them together in a bubble of privilege that prevents them from analysing the evidence. As we all do, they engage in post hoc rationalisations – in their case that that the poor are a moral underclass who are less intelligent, lazy, and hard working than the successful – to explain and justify their own positions.  This is almost a moral imperative, because not to blame the poor opens one up to the need to justify or critique the structural and economic privileges one has unequal access to. Placing the focus on the work, drinking and drug taking habits of a ‘moral underclass’ provides one with a sense of superiority and entitlement so much on show in both US and UK politics. No doubt the same occurs in Russia and China. To acknowledge that there are structural and economic conditions, for example the public school system or the service sector low wage economies,  or the inverse care law, opens up the middle class to accusations of champagne socialism.

This is a common tactic to deflect the argument away from an examination of causes to one of ‘ad hominem’.  Another tactic is to argue that the best way to address structural and economic factors is more of the same economic policies that have held sway especially in the US and UK. Indeed on a global scale the numbers of people living in absolute poverty is decreasing. Inequality is also decreasing with in the UK (gini coefficient). However these two factors are not the only issue.  Both the UK and the US are rich and other measures of inequality have increased, see for example the use of the Palma ratio. It matters greatly for very poor people to get incomes, and mortality rates, enjoyed by the poor in the UK and the US, but that is not enough as the social, health and political problems in both countries testify.

Privilege looks around and is satisfied knowing that the ‘have nots’ only have themselves to blame. They reach for the moral underclass theory and publish it relentlessly in their newspapers and commentary. They also have the wealth and political power to ensure this ideology is accepted by the poor themselves. However, many do not. In this context:

The losers get sick.

The losers get poor.

The losers get defeated.

The losers get mad.

The losers get even.

‘Many professions take losers as the object of their studies and as the basis for their existence. Social psychologists, social workers, nurses, doctors, social policy experts, criminologists, therapists and others who do not count themselves among the losers would be out of work without them. But with the best will in the world, their clients remains obscure to them: their empathy knows clearly-defined professional bounds’ (Enzensberger 2005). Enzensberger (2005) goes on to argue:

‘one thing is certain: the way humanity has organized itself – “capitalism”, “competition”, “empire”, “globalisation” – not only does the number of losers increase every day, but as in any large group, fragmentation soon sets in. In a chaotic, unfathomable process, the cohorts of the inferior, the defeated, the victims separate out. The loser may accept his fate and resign himself; the victim may demand satisfaction; the defeated may begin preparing for the next round. But the radical loser isolates himself, becomes invisible, guards his delusion, saves his energy, and waits for his hour to come’.

Shoots a Policeman, drives a truck through a crowd, blows himself up in an airport…..all the while privilege looks on in dumb uncomprehending horror calling for more security and economic crackdowns on the moral underclass upon whom the often middle class radical loser preys.

Hunt’s agenda

The ideology of health care provision.

 

 

Amid the junior doctors strike of 2016, the health secretary Jeremy Hunt was embroiled in a conflict with the BMA over doctors’ contracts designed to address a 7day NHS. This is the surface issue but sits upon a deeper ideological conflict, one that many of the doctors will be unaware of but will suspect, especially if they have read Alysson Pollock’s works on the privatisation and corporatisation of the NHS. Hunt argued he has a ‘mandate’ to introduce a 7 day NHS and perhaps realises that if this policy cannot be introduced, the balance of power over the future of the NHS will swing back towards the BMA and other health professional groups. The irony is that the BMA opposed the introduction of the NHS back in 1948 but now is one of the strongest supporters. Since 2012 however, the NHS has been dismantled and been replaced with privatised and corporatized service provision, with ‘patient choice’ and ‘patient safety’ being used as the ideological veil which masks the corporate face. People have not noticed this detail because so far ‘free at the point of delivery’ is still in place, but this principle, along with universal and comprehensive cover, is under threat. The government remain the almost monopoly purchaser of health services on our behalf but for how long? The care home crisis points in the direction of travel. This will be withdrawal of state funding and reliance on private provision which will not be ‘free at the point of delivery’.

 

 

 

In 2005 ‘Direct Democracy – an agenda for a new model party’ was published, the authors include the current health secretary Jeremy Hunt. It is not government policy and does not represent the full range of conservative views. The Tory party itself is home to those of a ‘one nation’ persuasion who mix ideas of ‘noblesse oblige’ with a modicum of a social welfare, safety net, public service ethos. It is also home to ‘neoliberalism’ rooted in anti State sentiment based on freedom of the individual and free market economics. This ideology can be clearly seen in the 2012 book ‘Britannia Unchained – Global lessons for growth and prosperity’ which argues for further free market economics based on a bonfire of employment laws. The book suggests:

 

“The British are among the worst idlers in the world. We work among the lowest hours, we retire early and our productivity is poor. Whereas Indian children aspire to be doctors or businessmen, the British are more interested in football and pop music.”

 

This one quote conveys the disdain neoliberals have in general for those less well paid, less “successful” and less powerful than themselves. Boris Johnson’s speech in 2013 on the impossibility of equality being based on differences in IQ, implied some people are too stupid to get ahead. This individualises issues, while ignoring structures of class, gender, ethnicity and privilege. He said:

 

And for one reason or another – boardroom greed or, as I am assured, the natural and god-given talent of boardroom inhabitants – the income gap between the top cornflakes and the bottom cornflakes is getting wider than ever. I stress: I don’t believe that economic equality is possible; indeed, some measure of inequality is essential for the spirit of envy and keeping up with the Joneses that is, like greed, a valuable spur to economic activity.”

 

Two ideas are core here: that the working class and the poor are so because they are more lazy and stupid than the ruling class, and that the answer to this is to increase competition and to use inequality as incentives for personal improvement. Of course said like that to the electorate, it would seriously threaten voter support. Instead the discourse of market efficiency, effectiveness and choice is used to justify privatization and corporatization of public services. The message to the public is clear: take responsibility for education, health, social care and housing. It is down to individuals and families to provide by working hard and being prudent.

 

The arguments over the NHS have to be seen within this wider context. At heart, many in the current Tory party viewed the state run NHS as anathema. As such they have succeeded in dismantling the post war structure of the NHS following the Health and Social Care Act 2012. This allowed for private providers to bid for the provision of health services but keeps in place, for now, principles such as ‘free at the point of delivery’.

 

According to Alysson Pollock, the Health and Social Care Act 2012:

 

  1. Removed the duty of the Secretary of State for health to secure and provide health care for all.
  2. Introduced US style insurance schemes.
  3. Gives the secretary of state legal powers to create a market, allows providers to pick and choose which patients will get care, services to be provided and what will be charged for.

 

A market has been introduced into health service delivery, and markets operate through risk selection and appraisal resulting in fragmentation of provision. That is to say a market provider needs to pick and choose which patients are profitable in competition with other providers. We now have clinical commissioning groups modelled on insurance based lines. Those with high risk or multiple needs will be expensive to provide care for.

 

The ‘NHS’ is now fragmented in which:

 

  1. Services are broken up and put out to tender to commercial companies.
  2. Commercial shareholders have new legal powers to decide who gets care, what the get and what they pay for.

 

This current state of affairs is not enough for neoliberal thought. So what is the vision of this group of neoliberal Tories? How did this happen?

 

Direct Democracy argues:

 

“Several other countries operate political systems based on localism and direct democracy. Two outstanding examples – one much smaller than the United Kingdom and one many times larger – are Switzerland and the United States. In their different ways, both states respect the principles of the dispersal of power, the direct election of public officials and the use of the referendum as a legislative tool. Our proposals for the devolution of power directly to the citizen – notably in the fields of education and health care – have also been successfully trialled abroad, often in unlikely places. No less corporatist a state than Sweden has introduced a form of school voucher, while almost every state in Europe, at least since the fall of the Berlin Wall, now provides for an element of health insurance”.

 

This goes to the heart of the matter, note how the US and the Swiss are held up as models. The principles of localism and direct democracy are invoked as justifications hiding their argument and belief about market mechanisms. The United States is a beacon for the dispersal of power? One cannot expect anything other than this nonsense from neoliberals, wilfully ignorant as they surely must be of the work of C Wright Mills, Herbert Marcuse, Jurgen Habermas, David Harvey, Thomas Picketty, Graham Scambler, and Yanis Varoufakis? This also ignores the literature on social inequalities and inequalities in health and the social and political determinants of health. At this point we must also point to the wealth of feminist and post-colonial literature on ‘power’. In short it is an invocation of bourgeois patriarchal perspective on the exercise of power which blinds them to actuality.

 

As for Switzerland, the OECD reports that compared to the UK’s 9.3 % of GDP, the Swiss pay 11.4%. The UK used to pay under 6% but has seen a rise, not totally due to actual health spending but to cater for administration and profit for private companies. The US spends 16.9% (OECD 2014) and has introduced ‘Obama care’ to address the plight of uninsured americans. Obama care is an outcome of class struggle which has been hotly contested in the ‘land of the free’.

 

 

 

‘Direct Democracy’ claims to hold to three principles:

 

  1. Decisions should be taken as closely to the people they affect.
  2. Law makers should be directly accountable.
  3. The citizen should enjoy maximum freedom from state control.

 

 

On the face of it who would argue with that? Certainly not anarchists, socialists or libertarians. The problem is that these principles exist within a social and historical context, one characterised by imbalances of power along class, gender and ethnic lines and this cannot deal with the reality on the ground. Hunt et al are blind to the context in which ‘men of wealth buy men of power’, a world in which the capitalist class executive and the political power elite exercise a new class/command dynamic which neoliberal ‘reforms’ ushered in since about the 1980’s especially in the US and UK.

 

Yanis Varoufakis (2016) clearly discusses the effects of such things as the “Nixon Shock’ on the post war global financial settlement, the outcome being that the ‘strong do what they can and the weak suffer what they must’. Global health corporations need new markets and looked to the UK’s NHS as a source of rich pickings. This is the context in which Hunt’s bourgeois democracy operates.

 

  • Decisions about who provides health care, what health care looks like and where it is provided are taken by unelected clinical commissioning groups operating within a profit driven market context.
  • Patients do not have an electable secretary of state who has a statutory obligation to provide health care services.
  • Freedom from state control for health service provision has morphed into control via corporate decision making.

 

 

Direct Democracy (2005) argues:

 

‘The problem with the NHS is not one of resources. Rather it is the system remains centrally run, state monopoly designed over half a century ago’ (p74).

 

Clearly this is a statement that ‘the system’ needs to go. The resource issue in the context of increasing demands and costs is brushed aside. This remark now looks questionable at best in 2016.

 

“We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the State.” (p74).

 

Holding on to a notion of ‘free at the point of delivery’ implied here, it is clear that private provision is to be introduced. The language is anodyne, context free, taking no notice of what private provision might look like, who would provide it and what the consequences of the inevitability of a market might be. The State at least has a role in providing for the poor. The writers of this document are part of the political power elite, or may wish to be, and the coherence of interests with the corporate/capitalist class executive are hidden. Those who sell insurance have not been lobbying for this change then? A bit of research into who benefits from this change might prove insightful. Are there links between corporate interest and the politicians who are driving the changes?

 

Hunt et al feared the NHS would only be second to the US in terms of % of GDP spent. This has not occurred. They report a study ranking the UK 18 of 19 countries. This is selective in the extreme, and is now way out of date.

 

Many of the critiques they evoke of the NHS are a result of the rise of new public management, or ‘managerialism, introduced into the system by previous governments both New Labour and Tory. For about three decades managerial control, targets and distrust of professionals have eroded the ability of the NHS to be the best in the world.  The judgment about the efficiency and effectiveness of health services partly depends on what criteria are being used to judge them. The % spend of GDP is a crude figure as it hides a plethora of costs and profits.

 

Other measures of success could include universality of access, comprehensiveness of cover, mortality and morbidity outcomes, and the publics’ safety and satisfaction.

 

Mark Britnall has written ‘In search of the Perfect Health System’ (2015) of the complexity of comparing health systems. Britnall is no Tory ideologue and describes his approach as more brown mud than blue sky thinking:

 

He also wrote in 2011 before the 2012 Act:

 

“[o]f course, the vast majority of care – quite rightly in the UK context – will always be provided by public sector organisations (currently, about 95% of it) and will be paid out of taxation” and “[t]he issue of competition, which now seems to be conflated with privatisation, is unhelpful and misleading and, at best, only a small part of reform. Competition can exist without privatisation and the NHS can maintain its historic role in funding care while dealing with a richer variety of providers – public sector, social enterprise and private organisations”.

 

This 2011 comment predated the 2012 Act and can be seen as a statement of intent than actuality on his part. In 2010 there was some controversy over his statements in the US about private provision.

 

One area in which private provision is facing severe challenges is the care home sector.

 

Roy Lilley, writes a daily blog, and has considerable experience in the health service and with private sector organisations. He is no left wing radical. He writes in ‘They don’t matter’ (3rd May 2016) that success in private provision in the community has been ‘patchy’, citing Circle’s loss of £5 million and the paying of another £2 million to get out of the Hinchinbrooke contract, while SERCO and Bupa ‘bailed out’ of provision leaving Virgin clinging on. He argues that the private sector can be nimble and quick to adapt, but of course needs to make a profit.

 

However, the largest care home provider, Four Seasons, is in talks to ‘restructure its debt’ as they face a 39% drop in profits. Most of their ‘customers’ have their fees paid by social services. This amounts to some local authorities paying £385 per week which is just not enough. The living wage is also an issue for them, they have over 30,000 staff but with no way of adjusting prices to pay for the increase and with no operating surplus. It has a debt of £510 million. If Four Seasons go broke they have 450 care homes at risk.

 

The bottom line is that health and social care costs money. There is not enough money in the system to pay for the care required. Some private families are paying £1,250 per week. Company Watch data which covers 20,000 homes, indicates that there is a funding black hole of half a billion pounds. This is market failure due to inadequate funding by design. It is almost as if the government is deliberately forcing people to find the money themselves either through savings, insurance or property while state funding through local authorities is slowly wound down.

 

Mark Britnall’s approach is scholarly, based in experience managing health care organisations and a deep knowledge and overview of many health systems. However, is Britnall sufficiently aware of the political economy of neoliberalism and its agenda for health?  Roy Lilley’s highlighting of the care home crisis clearly shows the political, austerity driven nature of the issue.

 

‘Direct Democracy’ and ‘Britannia Unchained’ are ideological approaches to health and social care. Whether Hunt has the temper for addressing Britnall’s insights or whether he still stands by the document he co-wrote is anyone’s guess. However, I know where the smart money would go. His face down of the doctors is more to do with power and who exercises it rather than the future of the health service as we knew it. If the neoliberals can get away with it, then free at the point of delivery will be severely challenged perhaps using spurious arguments stigmatising drug users, alcoholics, smokers, the obese, self harmers, self inflicted sports injuries, prostitutes, the promiscuous and Johnson’s ‘stupid’ as a wedge driven between the deserving and the undeserving ill. The care home crisis indicates that older people are ignored and the costs increasingly privatised as the state withdraws, or should we say abdicates, support. The NHS was to socialise risk, to spread its cost across the whole population. Instead we are rapidly moving towards individualising risk and private insurance based provision as the state withers away.

 

Choose your parents

Alejandro Nieto.

Bernal Heights. San Francisco.

What has the death of a young man, shot by four police officers in a park in California got to do with with understanding health outcomes in the United Kingdom?

Mary Sue and Miriam. Two women born at similar times whose grandparents came from the same small town in the United States. One will be going to an Ivy League University while the other struggles with drugs and hopelessness writing on her Facebook page ‘Love hurts, Trust is dangerous’.

What links them is that Alejandro and Mary Sue ‘chose the wrong parents’, while Miriam chose wisely, a Harvard professor for a grandfather (Robert Putnam), and University educated parents.

Their cases illustrate that health and well being is ‘structured but not determined’, that to truly understand their life chances we have to consider the transformations in society that impact on the choices made and opportunities open to individuals and their families.

Alejandro was born to Mexican immigrants who came to San Francisco in the 1970’s. His mother worked all her life while his father took on most of the child care duties. San Francisco has a history of immigrants from other parts of the US as well as from elsewhere. Being Hispanic in California is ‘normal’ but not to the white, male, educated tech engineers from Silicon Valley who have moved to the area en mass ushering in gentrification and myopia. Alejandro was described to the Police as probably ‘foreign’ who had a gun, his red jacket marking him out as a gang member. All of this was supposition and assumption. Alejandro had lived in Bernal Heights all of his life, the gun was a taser, carried because he worked as a security guard. His red jacket was a sports jacket, the colour of the local sports team the 49’ers. Those doing the describing were white tech engineers making assumptions about behaviour. Indeed, Alejandro was holding a taser, but he had just been harassed by a dog barking and jumping up at him to get at his chips. The dog owner was 40 feet away, distracted by a ‘jogger’s butt’ and unable to keep his dog under control.

The police arrived, and shot him, one unloading over 20 bullets and had to reload.

Alejandro, Mary Sue and Miriam live at a time when the United States is experiencing growing inequalities in wealth, segregation in its communities, family instability and a collapse of both good working class jobs now being followed by a squeeze on middle class opportunities. While the wealth of the 1% has increased based on their increased share of wealth being created – they are getting an even bigger slice of the pie, working class incomes have stagnated. Mary Sue’s grandfather used to have a decent income from a solidly working class job, now gone leaving ‘flexible’, low paid insecure work.

As economies restructure, as cities adapt to new social conditions, people experience changing social structures that enhance or diminish their chances. The white Ivy League tech engineers are likely to know only other white Ivy Leaguers, to come from Ivy League parents, went to the same schools and know only their own kind in a networked bubble of privilege, social myopia and self satisfying smugness. They don’t know the ‘other’ and can thus label a sports fan as a gang member with in this case lethal consequences.

Perhaps representing their views:

“I know people are frustrated about gentrification happening in the city, but the reality is, we live in a free market society. The wealthy working people have earned their right to live in the city. They went out, got an education, work hard, and earned it. I shouldn’t have to worry about being accosted. I shouldn’t have to see the pain, struggle, and despair of homeless people to and from my way to work every day.”

 

So ‘free market society’ justifies the breakdown of community, segregation, inequality, fear and mistrust. Wealth is ‘earned’ rather than a result of circumstances (right time, right family, right ethnicity, right gender, right neighbourhood, right education, right opportunities and often the inheritance of not only financial but social and cultural capital). Indeed, no one should have be be accosted, no one should see pain and struggle and despair, but don’t blame the victims of unjust social, political and economic systems. Don’t blame the dog for barking when someone’s kicked it.

Alejandro’s ‘personal trouble’ (being shot) is now a public issue. When only one young man is shot by police, we might consider the character of the man and look to him as an individual for reasons and solutions. When hundreds of young men are being shot by police this individual analysis is no longer useful, we must look to social structures, to link personal stories to this point in time in this particular society.

Miriam can look forward to a bright future, she experienced great parenting, great education backed up of course by well resourced material assets. Mary Sue, is a single parent with no education, self harm, a drug habit and abusive partners. Her child will very probably not go to Harvard. Alejandro made the mistake of being born Hispanic and thus a potential threat to the White denizens of a newly gentrified neighbourhood.

If you are struggling to apply this to the UK context, you don’t know the truth and you lack the ‘sociological imagination’.

Alejandro’s story is in Rebecca Solnit ‘Death by Gentrification’. Opinion. The Guardian. March 22nd 2016.
Mary Sue and Miriam’s story is in a talk by Robert Putnam to the RSA in London, March 2015, on ‘Inequality and the Opportunity Gap’. https://www.thersa.org/discover/videos/event-videos/2015/10/robert-putnam-on-inequality-and-opportunity/#

A manifesto for Action Nursing

A manifesto for Action Nursing

(Acknowledgement: Many thanks to Graham Scambler for his work on action sociology which inspired this manifesto).

“NOTICE: this is the author’s version of a work that has been sent for publication in Social Theory and Health.  Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may be made to this work since it was submitted for publication.

 

This manifesto calls for a social movement for political activism by nurses and other health professionals, to address inequalities in health and the social inequalities that highly structure, but do not determine, health outcomes. This action can operate at individual, clinical, organisational, national and international level.

 

Our aim is to respond to threats to health and socialised health service delivery from corporate, financial and political interests.

 

Our vision is for decreasing social and health inequalities in which the social gradient is greatly diminished.

 

Our goal is to create a networked social movement involving political and civic activism to bring critical understanding and action into the public sphere.

 

As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care, nurses must ally themselves with the progressive forces which seek to redress the balance of power of the ‘Greedy Bastards’. To paraphrase Graham Scambler, it is the largely unintended consequences of the actions of the ‘Greedy Bastards’ which results in gross social inequalities and inequalities in health. Action Nursing, alongside an ‘Action Sociology’, wishes to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from understanding care as vital, as central, to our ‘species being’ and is not mere adjunct, to be ignored within the private (female) domain.

As many governments embrace austerity policies within a neoliberal political economy, capital accumulation takes on various anti-democratic forms unaccountable to the people engaged in what Marcuse (1964) called ‘the pacification of the struggle for existence’.  The provision of nursing may be seen as a cost and not a benefit to those who decide where the investments should be made. Capital accumulation practices in health care delivery, especially in the care of older people and those with mental health issues, often results in absent or stretched services, or hiring under educated and poorly trained staff who too often lack supervision and development and who work in high patient to staff ratios. It also seeks private insurance based schemes and prefers services which can return profits. Care givers also work in the private domain, the informal sector, providing vital support to the wider business of capital accumulation but with very little or no recognition or return for such efforts. This ideology is maintained by appeals to the moral character of such work, often locating it firmly within kin networks as a ‘reciprocal gift’ that would be sullied by any suggestions of a cash nexus.

Nurse educators, clinicians and 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, or disdain apart from those engaged in teaching the social sciences in nursing. 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. 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.

Intrinsic to the nursing project is a concern for the health of individuals, communities and populations but in any point in history nurses will find themselves confronting ideologies; these are erroneous worldviews or theories that justify, sanction or provide cover for financial, business or political interests. Nursing’s ethics of care should include opposing forces that suppress truths about the societies we inhabit.

Nursing care in an often uncaring society should necessarily be oriented to justice and solidarity. It should be active not passive and should exist as a form of intervention against ‘distorted communication’ that interpellates nursing and nurses into subservient subject positions.  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 health services have no analytical tools or critical thought in which to contextualise and critique their experiences with vulnerable people. Critical theoretical concepts, such as ‘governmentality’ or ‘praxis’ or ‘frontiers of control’ ‘or ‘critical reflexivity’, would be sadly be alien to most nurses.

Action Nursing therefore contests the (often biomedical) ‘taming’ of nursing especially in the post-1970s neo-liberal era, including the shying away from arguing about contentious or ‘risky’ issues. Witness the uncritical passivity with which nurses in the UK have accepted ‘values based recruitment’, the ‘6Cs’ and ‘revalidation’ as panaceas to the issues of the quality of care; witness as well the lack of action regarding the structural conditions of the NHS following the Health and Social Care Act.

 

An Action Nursing cannot stand on the sidelines as a passive recipient of the decisions made by other powerful actors. It has to dwell on exploitation and oppression that result in inequalities in health for the population and stress, burnout and compassion fatigue for nursing staff and other care givers in their homes. Action Nursing should engage in the Marcusian ‘Great Refusal; it stands against the actions of the wealthy and powerful and actions whose consequences include the social gradient seen in the mass of data on health inequalities and evidenced in people’s lives in such works as ‘The Life Project’ (Pearson 2016).

 

This manifesto also allies itself with the manifesto ‘from Public to Planetary Health’. This is the voice of health professionals who together with empowered communities could confront entrenched interests and forces that endanger our future. This could be a powerful ‘social movement from below’ based on collective action at all levels to create better health outcomes, protect our futures and support sustainable human development.

Marcuse H (1964) One Dimensional Man. Routledge. London.

Pearson H (2016) The Life Project. Penguin. Allen Lane. London.

The missing two C’s – commodity and critique

http://tinyurl.com/the-missingtwoCs   This is the link to the published article in the Journal of Research in Nursing.

This discussion paper argues for understanding nursing care as a commodity within capitalist relations of production, ultimately as a product of labour, whose use value far exceeds its exchange value and price. This under recognised commodification of care work obscures the social relationships involved in the contribution to the social reproduction of labour and to capital accumulation by nursing care work. This matters, because many care workers give of themselves and their unpaid overtime to provide care as if in a ‘gift economy’, but in doing so find themselves in subordinate subject positions as a part the social reproduction of labour in a ‘commodity economy’. Thus they are caught in the contradiction between the ‘appearance’ and reality. A focus on the individual moral character of nurses  (e.g. the UK’s 6Cs), may operate as a screen deflecting understanding of the reality of the lived experiences of thousands of care workers and supports the discourse of ‘care as a gift’. The commodification of care work also undermines social reproduction itself. Many nurses will not have tools of analysis to critique their subject positioning by power elites and have thus been largely ineffectual in creating change to the neoliberalist and managerialist context that characterise many healthcare and other public sector organisations. The implications of this analysis for health care policy and nursing practice is the need for a critical praxis (an ‘action nursing’) by nurses and nursing bodies, along with their allies which may include patient groups, to put care in all its guises and consequences central to the political agenda.