Is discrimination of body size a new form of classism? The Chilean case

Maria Alejandra Energici

There are two facts about obesity that are well documented and tend to be common to many societies. First, rates of obesity are higher in poorer populations (Darmon and Drewnowski 2008; Drewnowski and Darmon 2005; Drewnowski 2004). It is a well-known and simple fact: in developed or developing societies, moving down in the social scale is accompanied by an increase on the rate of obesity. On the other hand, a second fact that has remained almost unrelated to the first one is that obesity is a very stigmatizing condition. Many aspects of an obese person are affected by his or her weight: school or work, home and public life, among others (Sobal 2011). For example, obese individuals have a lower probability of finding a job (Grant and Mizzi 2014) or to be selected as possible dating mates (Guzman, del Castillo, and García 2010). Even discrimination from health professionals has been observed (Pantenburg et al. 2012; Sobal 2011).

I have been conducting research about the social construction of fatness by adults and young people in Santiago, Chile. We analyzed ‘fatness’ instead of obesity, in part to inquiry if fatness is considered a disease. We recruited six discussion groups, three of young people, three of adults, each containing representation from the different socioeconomic groups.

It seems that fatness is constructed as a three dimensional problem: it is a physical condition, not necessarily a disease, and more of an enlargement of the body and a deterioration of the fitness of the body; a psychological condition determined by low self esteem, lack of self control and discipline; and an aesthetic condition of ugliness and deformation.

The traits used to describe (and consequently discriminate against) fat people called to mind both class-divisions and common characterizations of poor people. To elaborate: Chile is a very unequal, class-divided and segregated society. People from any given social class tend to frequent the same places, attend the same schools and live in the same areas of the city. They commonly befriend and marry people with the same socioeconomic status.  As a consequence, social class is a very important dimension of social interaction. In Chile, people are very fast to discern someone’s social class: it is essential for interaction so they can know if they have to treat him or her as an equal or as a ‘stranger’. Fatness seems to be one of the traits that helps people to make rapid, spontaneous judgments; all those who have participated in the study have openly declared that poor people tend to be fatter than rich people. So fatness or obesity in poorer populations is not only of academic interest, but also important for social interaction.

But it is not just that body size helps to categorize someone’s social class, it also endows them with a series of traits that are very similar to the ones traditionally attributed to poor people. In a society characterized by neoliberal ideas, poverty has been constructed as an individual matter; that is, poverty is not explained in terms of social or economic causes but rather in terms of personal choices. ‘Laziness’ plays a key role in this kind of explanation: a person is poor because he or she is indolent. Sadly this is not an uncommon judgment in the Chilean society. What interests me is that fat people are described in very similar terms; for example, a sedentary life style is highlighted as the main cause of fatness. The sedentary lifestyle is not put down to a lack of exercise, rather it connotes a morally connoted state of “doing nothing” or laziness. Fat people are the way they are because they are lazy; they prefer to watch television instead of exercising; they prefer to eat fast food instead of taking the time to prepare something healthier. As a consequence, laziness becomes a key aspect to explanations of fatness.

If we take together theses two judgments, that poorer people tend to be fatter than rich people and that fat people are like that because there are lazy, we have the same net result, namely, poor people are lazy. Laziness, traditionally used to explain the condition of poverty, now is extended to bodies. The laziness marks the body in a way it didn’t before. This is what leads me to think that in the Chilean case discrimination of body size could be a form of classism where the body symbolizes laziness by its shape.

With this study we have become very aware that stigmatization and discrimination over body size don’t occur in a social vacuum. They interact with other forms of exclusion or violence. It has been shown how discrimination by body size tends to exacerbate violence to women (Fikkan and Rothblum 2012; Rothblum 2011). What our research is showing is that we should also study how it interacts with classism.

 

References

Darmon, Nicole and Adam Drewnowski. 2008. “Does Social Class Predict Diet Quality?” The American Journal of Clinical Nutrition 87:1107–17.

Drewnowski, Adam. 2004. “Poverty and Obesity : The Role of Energy Density and Energy Costs.” The American Journal of Clinical Nutrition 6–16.

Drewnowski, Adam and Nicole Darmon. 2005. “The Economics of Obesity: Dietary Energy Density and Energy Cost.” The American Journal of Clinical Nutrition 265–73. Retrieved (/Users/grahamjeffries/Documents/literature/Am J Clin Nutr 2005 Drewnowski A.pdf\nhttp://www.ajcn.org/cgi/pmidlookup?view=long&pmid=16002835).

Fikkan, Janna L. and Esther D. Rothblum. 2012. “Is Fat a Feminist Issue? Exploring the Gendered Nature of Weight Bias.” Sex Roles 66:575–92.

Grant, Sharon and Toby Mizzi. 2014. “Body Weight Bias in Hiring Decisions: Identifying Explanatory Mechanisms.” Social Behavior and Personality 42(3):353–70. Retrieved (http://openurl.ingenta.com/content/xref?genre=article&issn=0301-2212&volume=42&issue=3&spage=353).

Guzman, Rebeca Maria Elena, Arturo del Castillo, and Melisa García. 2010. “Factores Psicosociales Asociados Al Paciente Con Obesidad.” Pp. 201–18 in Obesidad. Un enfoque multidisciplinario, edited by José Antonio Morales. Hidalgo: Universidad Autónoma del Estado de Hidalgo.

Pantenburg, Birte et al. 2012. “Medical Students’ Attitudes towards Overweight and Obesity.” PLOS ONE 7(11):1–8.

Rothblum, Esther D. 2011. “Fat Studies.” Pp. 173–83 in The Oxford Handbook of Social Science of Obesity, edited by John Cawley. Oxford: Oxford Univesity Press.

Sobal, Jeffery. 2011. “The Sociology of Obesity.” Pp. 105–19 in The Oxford Handbook of Social Science of Obesity, edited by John Crawley. Oxford: Oxford Univesity Press.

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Why philosophy matters?

Joanna Moncrieff, Psychiatrist, Senior Clinical Lecturer in the Division of Psychiatry, University College London and co-chair of the Critical Psychiatry Network.

Reproduced from Dr. Moncrieff’s blog, with permission. See https://joannamoncrieff.com/2017/09/22/why-philosophy-matters/amp/

This is the first of a series of blogs presenting a philosophical analysis of the modern mental health system and what it is concerned with.

20th century philosopher, Ludwig Wittgenstein, much of whose later work concerns our thinking about the ‘mind’, suggested that the role of philosophy is to identify and clear-up conceptual confusions. Many of these confusions have been introduced by philosophers, asking the wrong questions in the wrong way. Wittgenstein hoped to show that by understanding the nature of language more accurately, many of the most complex dilemmas of philosophy just melt away.

This idea of tidying up our language might sound like a rather modest activity, of little practical importance, but it is not just philosophers who have been beguiled by muddled uses of language and led astray by fruitless debates. These confusions have permeated everyday thought. They influence our behaviour as individuals, and structure the social institutions we build. Nowhere is this more apparent than in the system we now call ‘mental health.’

Thomas Szasz is, of course, the most well-known person to have called attention to the conceptual confusion embedded in the term ‘mental illness’ (1). For Szasz, illness and disease are concepts that are inextricably bound to the body, hence a non-bodily, non-material concept such as the mind cannot be ‘ill’ (2). Situations that are referred to as ‘mental illness’ are defined by certain sorts of problematic behaviour, not by the biological dysfunction that is characteristic of regular illness. Szasz also understood that the confusion inherent in the concept of ‘mental illness’ did not simply arise because people were misguided, it is what he called ‘strategic.’ Designating certain problems as ‘mental illness’ justifies particular social arrangements and it does so because the terms ‘illness’ and ‘disease’ derive their meaning from being a condition of the body.

I will return to the crucial issue of whether or not an illness is necessarily a bodily characteristic in later blogs, but now I just want to illustrate how important this question is. Whole social systems depend on the assumption that what we call ‘mental illness’ or ‘mental disorder’ (a piggy-back term) originates in the body. In particular, this notion is fundamental to the current social response to certain forms of behaviour, and to processes for allocating resources for assistance or welfare.

In modern societies, the use of force by some individuals against others is considered unacceptable and is illegal. The state reserves a right to use force in some situations, but only against those who have broken the nationally agreed code of conduct – the law. However, if someone’s thinking and behaviour are thought to be the result of an aberrant biological process taking place within the body or brain, a process that has nothing to do with the personality or agency of the individual (which is what I will argue is the usual understanding of the term ‘disease’), then the individual logically forfeits the right to be regarded as an autonomously-acting being. What she does and says in these circumstances can legitimately be disregarded. Efforts to change her behaviour, which may involve the use of force, can be conceived of as a medical ‘treatment’ that is aimed not at the individual per se, but at the underlying disease.

Think of the contrast between compulsory community treatment orders or outpatient commitment for people diagnosed with mental disorders and the use of libido-suppressing agents for sex offenders (sometimes referred to as chemical castration). Although these drugs can be imposed on convicted offenders as part of sentencing in some parts of the world, in most of Europe, sex offenders have to give their consent, and in the United Kingdom, a second opinion is also required for the drugs to be administered by injection. Under out-patient commitment laws, someone who has a diagnosis of mental disorder, but has never harmed anyone, can have her body chemically altered against her will for the rest of her life, despite having the capacity to make a perfectly rational decision about this for herself. This is not imposed as a punishment for misbehaviour (at least not explicitly), and  would not be acceptable in modern, western society without the implicit assumption that having a ‘mental disorder’ is equivalent to having a bodily disease. This enables the expressed wishes of the individual to be disregarded since she is no longer viewed as an autonomous agent, but as an object that is driven by the biological process taking place in her brain.

The idea that mental disorder is a disease is also the basis of modern welfare systems and crucially important for enforcing the modern work ethic. The characteristics of the ‘sick role,’ described by Talcott Parsons, derive from the nature of diseases as biological processes. People who have a disease have exemptions from normal social expectations and entitlements to care and support because of the recognition that biological events are not (often) under human control (3).

Modern society has no other way of excusing people of their social obligations. Although we recognise that numerous common life events (relationship breakdown, loss of a job) can make it difficult for people to cope with their daily duties, only a medical certificate verifying that someone is ‘sick’ (the ‘sick note’) entitles them to time off work, or financial assistance without the obligation to seek work.

I am not claiming to say anything new here. Szasz has made these points for decades (4). There is a tendency within mental health circles to fudge or avoid the issue, however. Proponents of the ‘biopsychosocial’ model appear to suggest that mental disorders can be both a biologically-driven process and a behavioural condition at the same time. Others claim that mental mechanisms and biological processes are the same thing, and hence can be sick or diseased in the same way (5). Although the term ‘mental disorder’ appears to avoid criticisms of the concept of mental illness, in reality it serves the same purpose, and hence ‘piggy-backs’ on the concept of mental illness.

I simply want to stress that fundamental aspects of western society depend on the equation of certain social problems with bodily conditions or illnesses. Without this, the concepts of mental illness or mental disorder cannot do the work they currently do. They cannot form the basis of the social systems they currently sustain.

What disease or illness is rightfully thought to be, and whether these concepts should, or should not, include the problems we refer to as ‘mental illness,’ has hugely significant consequences. It turns out that clarifying conceptual confusions may have a profound impact on modern society.

In the next blog in this series, I will look at the philosophy of Wittgenstein in more detail, and how it relates to our understanding of the ‘mind’ or the ‘mental’

Notes

  1. Szasz, T. (1961) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper.
  2. Szasz, T. (2000). Mental disorders are not diseases. USA Today, January issue.
  3. Parsons, T. (1951). The Social System. London: Routledge and Keegan Paul.
  4. Szasz, T. (1989). Law, Liberty and Psychiatry: an inquiry into the social uses of mental health. Syracuse, New York: Syracuse University Press.
  5. I am referring here, among other’s, to Jerome Wakfield’s ‘harmful dysfunction’ hypothesis of mental disorder: Wakefield, J.C. (1992) Disorder as harmful dysfunction: a conceptual critique of DSM-III-R’s definition of mental disorder. Psychological Review, 99, 242-247
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Is it time to re-evaluate neurosis? The work of Wilhelm Reich

Tom Lennard

Is there such a thing as a mentally ill society? This question was, using slightly different words, posed by Russell Brand during an episode of The Trews in regards to the emotional fragility of the singer Sinead O’ Connor. There isn’t time to discuss the ins and outs of the video here, nor the subsequent response from O’ Connor. To believe that a society is mentally ill is to understand that all, or at least a significant number of human beings, are subject to irrational drives, drives that make those humans unwell, or suffer difficulties in their personal interactions. How and why this happens is another question.  Eclectic and eccentric psychoanalyst Wilhelm Reich, tried to develop and extend the Freudian concept of neurosis, and use it to analyse society. It stands to reason that anyone wanting to find out if our society is mentally ill will need concepts that can understand the personal as well as the social, and draw out the “how” and the “why.”

Much like his mentor and influence Sigmund Freud, Reich was concerned with sexual urges. In the 20th century psycho-analysis made the study and treatment of irrational drives its focus. Both clinicians considered that children were imprinted with sexuality as they developed, and the problems that adults brought with them to clinic came from their sexual development. The problem of mental health thus had a family locus. The harsh realities of life conflicted with the young’s instinctive urges and desires: pushed so deep were many of these urges that they became unconscious of them. This was the basis of “neurosis.” It was the analyst’s job to make these desires known to the “analysand.” For Freud this was enough – or at least there were some desires that could never be resolved – the “reality principle” was always going to be too strong. For Reich however this was not enough. He started to treat the person’s libido; in other words he sough to help the patient/client get to a state of healthy sexuality.  Reich had cultivated an interest in Marxism in his early career, and thus when the world appeared to impede people’s happiness and social functioning, this meant for him that the world itself needed to change. Already at this point, we can see how following his logic society is itself the patient.

Like Marx, Reich’s work was indebted to Feuerbach’s concept of alienation. Alienation – if somewhat simply explained – is the idea that things that naturally belong together are separated. Moral dualisms such as (Sex-Pol Essays xv) spiritual versus physical love, tenderness versus eroticism are not necessary opposites for Reich, but things that can co-exist. When opposed to each other in our mindset, this conflict forces certain desires  to become deviant ones. Those people that have these deviant desires become anxious and neurotic about their social interactions. The Function of the Orgasm contains several pages dedicated to the questions Reich was asked by curious 20th century students and attendees to his lectures – questions that from a 21st century perspective appear quite naïve. The mistreatment and oppression of women’s natural sexuality, in addition to the problems the young had with coping with their sexual maturity, was evidence of conflicted people living sexually unhealthy lives. What is more, this arrangement suited the ruling class. For it was not just the control of economic processes that kept the poor impoverished, but the sexual neurosis inherent in bourgeois morality. The icon of this neurosis was the ideal god-fearing, middle class family, who he attempts to critique in his early Sex-Pol Essays. Therefore to sum up, our society’s mental ill health was stratified along class and gender lines, and its people were not fully aware of some of the causes of their own repression.

Whereas many psychoanalysts turned away from studying “somatic” or bodily problems, Reich thought that these symptoms in patients could sometimes be put down to disturbances in mental health. But although he thought bodily and psychological disturbances had an innate connection, he was clear not to use psychoanalytic theory and method for explaining everything. Russia’s arid revolution was guilty of an over-reliance on economic concerns. Despite having a pertinent, in his opinion, conception of social conflict, Marxists had misconstrued psychoanalysis as a middle class luxury, and lacking materialist basis. To counter this, in Sex-Pol Essays, he points out that left wing theorists should stick to interpreting social events sociologically or socio-politically. A strike, for instance, cannot be caused truly by the neurosis of workers who feel threatened by a “paternalist” factory owner. The irrational or unexpected behaviours that either strikers or managers display deserve psychological analysis. Furthermore, he notes how Engels demand that in order to be materialist, a philosophy has to be based on the organic, or at least on life processes. Both sex (at least its limited form “reproduction”) and labour are necessary conditions for continuous human existence. This makes a philosophy based on them materialist. Thus Reich spends a great deal of time in later work trying to weave together the idea of a “sex-economy.” The type of mentally ill society we live in is a “sex economy,” and neurosis a key problem. Neurosis serves to explain how a society degenerates into civil war and hatred, and appeared as a factor for the rise of Nazism in his native Austria – widely discussed in his work The Mass Psychology of Fascism.

It might be important at this point to go over what has already been discussed. Reich asserts that the “the reality principle” benefits the ruling class. Society is mentally ill: the conditions for producing neurotic individuals repeat themselves again and again. But the problem is also one of economic forces. Thus for Reich, a progressive politics needs progressive mental health ideas to ensure its success. If we accept that much of this damaging neurosis occurs to people whilst they are growing up, then sexual education is an important concern. Like many medical professionals he saw that prevention is vital. It was “easier to prevent a neurosis than to cure it” (The Mass Psychology of Fascism).

However Reich’s conceptions were much maligned. It is notable that The Diagnostic and Statistical Manual of Mental Disorders removed the term “neurosis” in 1980, ostensibly because it was too vague, and smacked off Freudian methods. Like Marxism, at least in its Soviet incarnation, psychoanalysis feels like a product of the last century. The methods of modern psychologists are far more mixed and some consider psychoanalysis a historical artefact. Sometimes on its 20th century journey it took dark turns, and Freud’s followers fought jealously over the right way to continue his legacy – Reich, and his legacy, became a casualty of this battle. If we regard society to still be mentally ill, we have to accept a berth of changes to sexual habit and close relationships in recent years.

Despite many flaws, Reich’s work presents us with an opportunity to link problems of psychological and sexuality to issues of work and labour. Neurosis may be discredited by many clinicians, but it presents us with a way of looking at mental health within a given social context, alongside other tools and methods. But neurosis needs considerable updating if it is used to explain the post war period. The society in which we live in may or not be mentally ill, depending on ones criteria or ones definitions. But the task of changing society for the better cannot ignore how sexuality is produced, and cannot take the present situation as an adequate one, when so many within society still suffer.

 Sources
The Mass Psychology of Fascism
Sex-Pol Essays
The Function of the Orgasm
The Trews: https://youtu.be/GMawuD0fQ5Y

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Tackling Stigma in Mental Health

Graham Scambler, STH co-Editor

The attention publicly devoted to mental illness is far from being matched by properly funded treatment and care. Nor, it seems, has it shaken off an overly long history of cultural shaming and blaming. In this brief contribution I focus in particular on the stigma that still sticks like glue to many diagnoses of mental disorder and of the means that have been considered for detaching it.

I will as a preliminary mention a terminological point. By stigma I refer to an offence against norms of shame. This does not imply culpability: it suggests non-conformance rather than non-compliance. I use the term deviance to refer to an offence against norms of blame: here a charge of moral opprobrium is clear. It has been conventional in modern times at least to link mental illness with stigma and shame rather than deviance and blame. This is changing however. I have referred elsewhere to a ‘weaponising of stigma’. My argument is that governments in post-1970s ‘financial capitalism’ have looked increasingly to attenuate the state’s funding responsibilities for health and welfare. They have sought to justify this by promoting a philosophy of ‘personal responsibility’ for those affected (and their families and loved ones). In other words, they have added deviance to stigma, blame to shame. It is increasingly as if people with mental illnesses are somehow causally and morally responsible for their misfortune and for dealing with any consequences. Medical help, let alone in-hospital treatment and care, has become a rare resource.

This political and cultural context has salience for interventions to remove or lessen the stigma associated with mental illness. Notably, it has become even more difficult to expect much by way of a return on programmes of stigma reduction that ignore context. Programmes like that of the World Psychiatric Association in 1996 to increase awareness and knowledge of the nature of schizoprenia and treatment options, to improve public attitudes towards individuals with schizophrenia and their families, and to encourage action to eliminate or reduce prejudice and discriminatory behaviour, have been swimming against strong political and cultural tides.

As well as interventions that fall under the general rubric of ‘education’ are others under that of ‘contact’ and ‘protest’. The thinking underlying contact interventions is that familiarity mitigates against attributions of shame, and more so blame. But circumstances are important: knowing an attractive or charming person with mental illness who is successful in his or her work roles might well take the sting out of any propensity to stigmatise, but he or she might also be stereotyped as ‘unusual’ and re-classified as belonging to ‘us’ rather than ‘them’.

While it would be wrong as well as ungenerous to chastise professional and lay bodies alike for placing too much faith in education and contact initiatives, their limited effectiveness is well documented. So what of interventions that focus on protest? Unsurprisingly, and unlike those around education and contact, these tend to be bottom-up rather than top-down. Programmes in Europe and the USA have had some encouraging results, although it has proven easier to change ‘behaviour’ than ‘underlying attitudes’.

I have suggested that anti-stigma interventions might be optimally effective when constructed on the basis of an enhanced understanding of those personal and social circumstances favouring: (1) the rejection of external attributions of shame and blame on the part of people with mental illness, without them (2) falling foul of internalisation of those same attributions. Adapting the sociologist Bourdieu, the priority might sensibly be avoiding a ‘mental illness habitus’ (or mind-set).

The tough message, however, remains this: personal ‘empowerment’ is likely to remain ineffective in the absence of broader institutional and structural change. ‘Unintentional’ institutional and structural discrimination are the true culprits. Bluntly, infringements against cultural norms of shame and blame can rarely be separated from the likes of exploitation, marginalisation, powerlessness, cultural imperialism, symbolic violence and so on.

Acknowledging such institutional and structural underpinnings to ‘the stigma of mental illness’ will in all probability surprise and unsettle medical professionals, including psychiatrists, more than participants in lay bodies contesting orthodox, and largely ineffective, professional interventions ‘on their behalf’. So be it. The bottom line as far as I am concerned is this: capital buys power sufficient to shape policy to its advantage. How to translate this? The principal force sustaining, indeed deepening (via ‘accusations of deviance’), the stigma of mental illness is that set of policies, epitomised in ‘austerity’, that accomplishes the transfer of capital from the exploited, marginalised and powerless to those born to inherit and rule.

If people find this concluding statement hyperbolic, then their potential to bring about the diminution of mental stigma is correspondingly reduced.

This blog owes much to:

Scambler, G (2011) Stigma and mental disorder. In Eds Pilgrim,D, Rogers,A & Pescosolido, B: The Sage Handbook of Mental Health and Illness. London; Sage.

 

NB: This blog post was originally featured as part of Palgrave Macmillan’s Mental Health Awarenss campaign.

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A Sociology Clinic: A Sociology of the People, by the People, for the People?

Tor Anders Bye, Sociologist and Fellow, Sociology Clinic, Trondheim, Norway

The ‘sociology clinic’, established in the middle of the city of Trondheim in Norway by Aksel Tjora, Professor of Sociology at NTNU, was opened on 1st July 2014. It was a concept he had been nurturing for nearly a decade before a suitable and affordable location presented itself. The overriding aim was to take the practice, craft and trade of sociology out of its normal university setting and into the community. The rental agreement was concluded, the clinic formally registered as a business, and the venue adapted and decorated to – quite literally – present a shop window for sociology in Trondheim. Aksel set about recruiting a team of skilled and imaginative sociologists of all ranks to take up the challenge of introducing and integrating sociology into the local community.

The original vision for the sociology clinic was to take sociology from NTNU’s out-of-town, out-of-sight and therefore out-of-mind Dragvoll-campus, which is several miles from the city and as many thousand feet above it, and into the vigorous and challenging environment of the city centre.

As well as physically bridging the gap between ivory tower and the day-to-day life of citizens, the clinic team set about putting its expertise to use and out to tender. ‘We can cure anything but disease’, Aksel Tjora proclaimed! Nor was this a cry in the wilderness. The background research had been done and solid grounds existed for two complementary premises: first, that there was a need for community-based studies to inform and guide urban planners and commercial endeavours; and second, that it was possible and desirable to involve community bodies and citizens as participants in the research process. On a more ambitious scale, the clinic might prove a focus for professional sociological and policy-oriented investigations into the far-reaching effects of socio-cultural and institutional change on the city environment.

These themes find an echo in early projects based in the clinic. For example, a team of sociologists used qualitative methods to evaluate the deployment of Trondheim’s ‘culture fund’, and went on to appraise its effectiveness in relation to the fund’s long-term goals. At the same time, this study contributed to the broader understanding of the politics and economics of the cultural field. Another project involved collaborating with ‘Agraff’, a small architectural firm located not far from the clinic. One outcome was the genesis of the concept of ‘passiar social’, the sociability of passing by, of happenstance, which fed back into local planning. Localities are interrelated in complex and potentially dynamic ways:  how one area is revitalised can impact directly on another. In this case the significance leading people to walk by the docks of ‘Ravnkoa’ was maximised. These sociologies – of space, neighbourhood and community – have tangible ramifications for the health of citizens.  As we hoped, such projects yielded a twofold return: first, they informed municipal and commercial plans; and second, they refined C. Wright Mills’ ‘sociological imagination’ by requiring constant theoretical and conceptual innovation and improvisation away from the university campus.

A final, related aspiration long articulated by Aksel Tjora is relevant here. The sociology clinic has had a liberating effect for and on the discipline. Its physical separation has given it a degree of autonomy from the traditional or conservative constraints of the university bureaucracy. The clinic is an independent initiative, unattached and unaffiliated to NTNU. With this comes the opportunity to step outside a ‘McDonaldised’ academic culture that can value the mass production of peer-reviewed papers in high impact journals above originality, creativity, real-life problem solving and even education.

The concept of the sociology clinic is commended here. The work done within its confines in Trondheim has been very encouraging across all the fronts mentioned here. The sociologists who have shared coffees and conversations and studied and researched there have been able to do outside the conventions and canons found on the NTNU campus. Studies that could not have been conducted from the campus base have flourished from the clinic, most notably those involving close liaisons with local politicians, planners, commercial concerns and citizens. Engagement and participation have been constant motifs. The ever-evolving clinic team firmly believe in the concept. They believe too that work done within and from the clinic will in time feed its scholarship back into the mainstream discipline and enliven its orthodoxies.

Perhaps most of all, the clinic opens its door to the wider community. Sociologists come by, but so also do others, maybe just to ask questions or exchange an idea or two. The sociology clinic is proving an important step towards a sociology of the people, by the people, for the people.

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Easing of US Trade Embargo, the Cuban Paradox, and Lessons in Health Care: A Natural Experiment

Christopher J. Fries, University of Manitoba, Canada

Since 1960 Cuba has been a under trade embargo by the United States. The results of this embargo, imposed by one of the world’s wealthiest, industrialized nations on a country with a population of less than 12 million, have been grave for the nation’s economy and the formal health care system of Cuba, especially since the collapse of the Soviet Union. The loosening of trade restrictions announced by US President Obama in 2014 and now working their way through American Congress constitute an interesting natural experiment on the relationship between economic development and population health. It will be fascinating to watch how freer trade affects measures of population health status, such as life expectancy and infant mortality, in Cuba. However, the case of Cuba already holds lessons about the relationship of the health care system to population health.

During the Cold War period (1946 – 1989), the Soviet Block provided financial support and trade to Cuba that helped shield the island nation from the economic effects of the embargo. The embargo prohibits US companies and their subsidiaries from trading with Cuba. As part of the embargo, medicine and health care supplies cannot be traded to Cuba. After the collapse of the Soviet Union and with it, foreign aid, first the economy and then the health of Cuba suffered. For instance, Stanford University, School of Medicine, researchers Paul Drain and Michele Barry show that owing to food shortages, average adult caloric intake decreased 40 per cent, the percentage of underweight newborns increased 23 per cent, the number of surgeries performed declined by 30 per cent, the number of pharmaceutical medicines available declined from 1300 to less than 900, and Cuba’s total mortality rate increased 13 per cent.

However, and surprisingly, despite the embargo, Cuba has the highest average life expectancy and the lowest infant and child mortality rates among 33 Latin American and Caribbean countries. In fact, on several key measures of the health of a population, Cuba is doing about as well as, or even slightly better in comparison with the far richer countries of Canada and the United States! For instance, according to the latest data from the World Health Organization, at 78 years, average Cuban life expectancy is only four less than Canada’s 82 years and about the same as the US’s 79 years. The WHO reports that Cuba’s infant mortality rate (5/1000 live births) approximates Canada’s (4.6/1000 live births) and betters the US rate of 5.9/1000 live births.

Cuba is a poor country that spends about $405 per capita total spending on health care. This compares with the $4,610 spent in Canada and $8,845spent by the US. In other words, Canada spends more than ten times what Cuba does on health care and the US spends more than twenty times as much! Despite this and the challenges to the Cuban health care system stemming from the embargo, on many measures Cubans are as healthy as Canadians and Americans.

Though countries like the US and Canada spend much more on our formal health care systems than does Cuba, we do not receive matching returns in terms of population health. This is sometimes referred to in the health research literature as ‘the Cuban health paradox’. Cuba is achieving world-class population health outcomes on its developing-world budget. How is this possible? The Cuban experience clearly illustrates that there is more to health care than expensive, high-tech medical products and services. It is possible to spend less and get more! This is because, as the Cuban Paradox demonstrates, medicine does not equate with health.

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A Manifesto for Action Nursing

Benny Goodman, Lecturer in Nursing & Sociology, School of Nursing & Midwifery, Plymouth University

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’ whose actions have the unintended consequences of 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.

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