An instalment in the Politics of Care
In the Beginning
For nearly 200 years, concerns about individual and public Health have been a badge for progressive politics. The revolutionaries in Paris in 1790 saw healthcare as close to the most important element of the ancien regime that needed dismantling and replacing with something that would work for the people.
Fifty years later, in the 1840s, doctors played a significant role in creating socialism and communism. The health problems of workers and the clearly unsanitary state of new urban environments were put in the balance with private industries, which driven by capitalism, showed little concern for workers’ health or the environment. Industry was found wanting. A focus on individual and public health offered a way to get industry to improve working conditions, including pay, and to get governments to factor the interests of citizens into policies.
An interest in the latest techniques and the contribution these could make to efficiencies was also a badge for progressive politics. Liberal parties in the nineteenth century favored a turn to technology which led to new industries and medical developments. Liberals also favored an expansion of education.
Green New Deal or De-Growth?
Today, the changing global climate has brought Green politics into the frame for all of us. Most Greens view themselves as progressives.
The language of the arguments between those interested in, or hostile to politics that are Green or Sustainable, and between those worried about or dismissive of climate change and pollution, steers us to entrenched positions on economic battlefields. Some figure we have no option but to embrace radical change. For others, the changes sometimes proposed spell an end to life as we know it, a return to a more primitive level of society and a loss of belief in the capacities of human ingenuity, driven by market forces, to solve problems.
On the more socialist side of Green politics, there is divide between Green New-Dealers and De-Growthers. Green New-Dealers are close to classic socialists. They figure they need a seat at the table where productive techniques get brought into play – able to argue for a more Green alternative like electric cars as opposed to internal combustion vehicles. On this line of thinking, its not about shrinking the economy, it might even be about growing it.
The De-Growthers are more Luddite than communist in their belief that we need to step back from growing the economy – we need fewer cars and travel rather than just cleaner cars. We may need to let the economy shrink even if in the short term this could have dramatic impacts on all of us. The Covid pandemic has made more of us aware of the implications of growth and non-growth in a way that few could have predicted before it struck.
Controlled Green Healthcare
The Politics of Care relocates questions about sustainability into a healthcare domain in part to see whether doing this brings common ground into view.
Neither Green New Dealers nor De-Growthers mention much about healthcare other than as a consequence of a climate change that will lead to food shortages or lead to flood damage and wildfires that will lead to loss of life or lead to an air pollution that will cause respiratory diseases. These are real issues – a change in diet, pollution and physical activity could make a substantial contribution to health and minimize the number of premature deaths.
There is also a recognition of some not specifically Green issues such as containing the food industry marketing of suboptimal diets that lead to obesity with knock-on health consequences like diabetes, and the marketing by related industries of alcohol, tobacco and other hazardous products.
There is also a distinctively Green, but less often mentioned contribution to health, thatcame from epidemiological and occupational medicine studies in the 1950s of the hazards environmental toxicities pose to our health – 80% or more of cancers are likely to have an environmental origin. The warming of our climate is now so dominant an issue that it is often forgotten that these studies were in at the birth to the environmental movement.
In healthcare now, those laying out Green or sustainable principles (See Lancet references below of the Canadian Alliance for Sustainable Health Care, who produced the image above) call for:
- Reduced health consumption by promoting preventive services.
- Increase in public healthcare which will better steward resources and match supply and demand.
- Reduced emissions from healthcare staff, patients, and facilities – using perhaps the rise of virtual consults as a result of Covid.
- Increase in evidence based best practice.
Sustainable healthcare needs more than this. As things stand, principles like these will do more harm than good.
The reason we end up with principles like these is that the focus to date has been on classic productive industries, the chemical, petrochemical, armament, and other enterprises whose products lead to climate change and environmental degradation. For decades, progressive politicians have sought a seat at the table where decisions about production are taken confident the public will vote for them because many of us view our current problems as stemming from an industrial and polluting revolution – with some of the rest of us figuring well maybe but it also produced wealth and gave us cars.
The Technical Revolution
From a 2021 vantage point, the industrial revolution looks like one element of a more encompassing technical revolution that began just before and triggered the French revolution whose greatest symbol was the use of a new medical technique – the Guillotine – see Shipwreck in Maastricht.
From 1950 onwards, the manufacturing industry born around that time shed jobs, just as agriculture sector that it had replaced had done around 1840. The proletariat have vanished just as the peasants did – they are no longer there to be a revolutionary class.
Close to 80% of us are now employed in service sectors, of which healthcare is the biggest component. Our politics do not reflect this.
The service sector uses rather than produces chemicals and plastics. It leaves emissions in its wake. Making healthcare sustainable, however, is about more than reducing the use of these materials and the level of emissions from healthcare staff or patients travelling in cars to hospitals.
Service sector management practices, which themselves are part of a bigger technical revolution that took place 200 years ago, toxify our environment.
One of the greatest ironies is that these management practices have been billed as bringing an entrepreneurial spirit and private sector efficiency to health services and to education.
These practices in fact are algorithmic in nature and oriented toward finding operational or technical solutions to our problems – oriented to solutions that have produced the problems we now have in both the productive and service sectors. The latest algorithms foster demand rather than contain it.
Demand can only be contained through an exercise of discretion, but we have to work out a way to value discretion. Discretion cannot be operationalized in a manner that makes is ‘scalable up’. It is local rather than global. And this localisation starts with the fact that we have a body, even as the latest technique lets me communicate with people on the far side of the world. See Annemarie Mol’s Eating in Theory.
The service sector will not produce techniques like the plastic eating bacteria that might help with pollution, but it is key to producing a recognition of the need for judgement and a respect for the complex nature of technique. This is becomes most clear when we are faced with the adverse effects of a drug.
Sacraments or Poisons
Until recently, medicines were widely viewed as poisons from which good can be brought if used judiciously. All techniques share this character – they inevitably cause harm but good can be brought from their use if that use is judicious.
Instead, we now view medicines and techniques in general as magical. Within health algorithms, predicated on the idea that the magic lies in the latest technique, have turned healthcare into what are better called health services. When Joe Biden or any politician says we will Follow the Science, the will invariably Follow the Algorithm.
Science and politics don’t mis easily. Science generates questions rather than closes them down. Politicians want policies which people will follow without question. Invoking Science is saying there are experts and you and even I, JB, need to shut up when they speak.
In healthcare we have reached just the opposite point – a lot of the experts have lost a lot of their credibility and listening to an increasing number of them is dangerous for our health.
Healthcare needs a recognition that the magic lies in us. Locating the magic in us rather than in techniques is not a matter of inhibiting production or services, nor a matter of locating our problems in some original corporate sin but of harnessing production and services so that they serve us rather than having us serve them.
It’s a matter of producing health rather than consuming health service products.
We need an appreciation of the role our judgements make in shaping whether techniques work for us, not just in the short term, but overall. Our naïve embrace of technique undermines the current principles offered by Green advocates:
- Preventive medicine has been commandeered by pharmaceutical companies and it is now a major driver of health service use.
- Public Services now also drive the current growth in health services – reducing medication burdens has become a privilege of wealth. Waving a public health service wand over our difficulties will no longer work the way some hope.
- The virtual consults that stem from the Covid pandemic may reduce emissions but at a cost of increasing the technical character of health services, increasing services overall and reducing the close personal contact without which there can be no Care.
- Evidence based medicine is almost totally controlled by industry – see related posts.
The Politics of Care
The politics outlined on this site invites everyone concerned with sustainability whether from Green or traditional political parties, or none, to engage with changes in the climate of healthcare and ask – what would truly sustainable healthcare look like? A follow up question is does sustainable healthcare shed a light on global climate change?
There is an urgent need to grapple with the following facts:
- Life Expectancy has been falling for 5 years before Covid.
- Our falling life expectancies can be tied to the number of drugs we now take. To get what we want from treatment we should ideally be on no more than 3 medicines. Our values, not an algorithm, must determine what these 3 are.
- Our participation in genuine conversations about our health has been compromised as the literature on our drugs is entirely ghost-written. The greatest concentration of Fake literature on Earth has, for 30 years, centred on the drugs our doctors give us.
- Our conversations are further compromised by a lack of access to the data from the clinical trials on these drugs. This enables companies to spin their drugs as safe and effective when the raw data (if accessed) shows them to be ineffective and unsafe.
- For similar reasons, healthcare professionals cannot have genuine conversations with regulators or the managers of health services.
- This allows corporations to bring us health services that deliver us problems we never knew we had for which their drugs are the answer. Nowhere is this truer than in preventive medicine.
- This corporate approach is making the Healthcare climate toxic and lowering life expectancies.
- Just as the effects of accidents like Exxon Valdez increase GDP, so drug induced disabilities now sustain services rather than us.
- In addition to a corruption of preventive medicine, there is a more recent growth in wellbeing markets. This adds to a consumption of health products and to our medication burdens. It also imports identity politics into the health domain, further fracturing our abilities to find common ground.
- Healthcare cannot be an exercise in consumerism. Poisons and techniques that can backfire are not consumer items. Care must be relationship based. It hinges on wisdom and humanity rather than marketing, and algorithms.
- Green principles see the hazards of alcohol and smoking but fail to see a link to drugs that are prescription only because they are more hazardous than alcohol or nicotine.
- Medical drugs have been transformed from wine into sacraments – substances that can only do good. They are the exemplar of all techniques in that the magic needed to use them to good effect lies in us, but we are tempted to view the magic as lying in the technique.
- Salvation lies in participation (production) rather than consumption.
At the moment, the powers that be are very comfortable with the development of Green politics. Any proposal from an opposition that invokes a need for innovation (as in CASHC above) or adhering to the best possible evidence is not a problem. There is no pressing need to do anything to manage the proposers no matter how revolutionary, or anti-establishment they may seem, or how (to use the current status quo jargon) disruptive they may seem.
While they invoke innovation and new techniques, there is a good change they will control themselves. Token expressions of alarm from time to time may be useful to keep them on the right track – the same track.
For the rest of us there is a need to find the boundary between being part of a controlled opposition and a force for real change. This was brought home to me yet again lately when I was described as part of the controlled opposition.
References for Politics of Care:
Shipwreck of the Singular: Healthcare’s Castaways. Samizdat Writers Cooperative Toronto.
References for standard Green healthcare positions:
See CASHC above and the following from the Lancet Planetary Health available for download.
Barlow P, van Schalkwyk M C, McKee M, et al. COVID-19 and the collapse of global trade: building an effective public health response. Lancet Planet Health 2021; 5: e102–07
Dasandi N, Graham H, Lampard P, Mikhaylov SJ. Engagement with health in national climate change commitments under the Paris Agreement: a global mixed-methods analysis of the nationally determined contributions. Lancet Planet Health 2021; 5: e93–101
Fu-Chun MC. Accelerating towards net zero emissions: the most important global health intervention. www.thelancet.com/planetary-health Vol 5 February 2021 e64
Hamilton I, Kennard H, McGushin A, et al. The public health implications of the Paris Agreement: a modelling study. Lancet Planet Health 2021; 5: e74–83
MacNeill A, McGain F, Sherman J Planetary health care: a framework for sustainable health systems. Lancet Planet Health 2021, 5 e66-69.