The world of Policy and the Salzburg Statement

With his recent elevation to Taoiseach, something Leo Varadkar (who was supposed to work with me when I did a locum in Tallaght in May 2007… but he was occupied with some election or other) said in the late 1990s got a fair bit of coverage. This was to the effect that as a doctor you can help a few people, but as Minister for Health you can help millions. While at first glance this seems like a truism, it has for some reason got under my skin. There are various reasons for this, not all of which I will get into. Perhaps I am jealous of a road not travelled! (I am pretty confident I am not)

In a way it sums up a particular seduction – the seduction of the World of Policy. Get interested in any field – from the natural world to technology to medicine indeed – and sooner or later the siren song of policy will be heard. Wouldn’t it be great to Make A Difference not just on the piecemeal, day-to-day way, but on a grander scale? Increasingly I think not. Clearly someone needs to formulate policy and to think about things on a broad scale – but they should do so without illusions and with a certain humility. People have a habit of behaving in a way that the enlightened policy makers don’t foresee.  The circuit of conferences and “networking” can become an echo chamber of self congratulation. Doing good, perhaps, is best done on a smaller scale.

These thoughts are occasioned by reading about the Salzburg Statement. This is something I heartily approve of – a call for action to ensure all children enjoy the right to play in a nature rich space within ten minutes of their home.  The statement is made up of eight key actions:

Eight actions to transform cities for children

1. Ensure children of all ages, backgrounds, income, and abilities have equitable access to nature and play regularly and in meaningful ways to promote good health and wellbeing.

2. Embed nature in everyday places used by children, such as schools, backyards, parks, playgrounds and city streets, to make the city into a natural outdoor classroom.

3. Involve children in designing and planning natural spaces for recreation, education, inspiration and health, to give them ownership and pride in their local communities, schools and parks

4. Build curiosity, wonder, and care for nature in children (for example by greening school grounds and involving children with community gardens).

5. Protect natural features across cityscapes and create an equitably distributed network of accessible green and nature-rich spaces that all generations can reach on foot.

6. Connect cities with the broader ecosystems in which they are embedded, creating corridors for people, plants and animals to move safely across the city and into its surroundings.

7. Establish more urban conservation areas to increase access to nature and connect cities to the broader protected area network.

8. Work together through cross sectoral and multi-level partnerships to build an inclusive culture of health in cities.

 

There’s nothing there I would disagree with, though as with all these kind of interventions I would like more robust dissection of what, say, Item 3 would mean in practice.

I am always a little wary of dressing up worthy activity in the mantle of Health. What Resting a case for nature on the vagaries of purported health benefits can be a dangerous and debunkable game – especially with the media. This visual  handily shows how media can seize on single studies to generate headlines:

One can easily imagine a Katie Hopkins-ish journalist seizing on the inevitable ambiguities of research to “debunk” the claims for health benefits of nature.

I should state very clearly I have no reason to think that the Salzburg Statement is a wonderful initiative I look forward to hearing more of. But I am a little wary of the siren call of the World of Policy.

Anthropologizing Environmentalism – review by E Donald Elliot of “Risk and Culture”, Mary Douglas and Aaron Wildavksy, Yale Law Review, 1983

Recently I have been posting  on the cultural theory of risk developed by Mary Douglas and Aaron Wildavsky. This is a PDF of a review of Douglas and Wildavksy’s 1982 book “Risk and Culture” by E Donald Elliott adjunct professor of Law at Yale.

The review summarises Wildavksy and Douglas’ thought very well, and gets to the heart of one issue I struggle with in their writing ; their oft dismissive approach to environmental risk:

Most readers will be struck not by the abstract theory but by its application to the rise of environmentalism. This emphasis is unfortunate. The attempt to “explain” environmentalism makes a few good points, but on the whole this part of the book is crude, shortsighted, and snide. On the other hand, the sections that consider the relationship between risk and culture on a more fundamental level are sensitive and thoughtful.

I think it unfortunate that cultural theory of risk has ended up so much overshadowed by this “crude, shortsighted, and snide” discussion of environmental risk (Wildavksy, if I recall correctly, was revealed to have taken undisclosed payments from the chemical industry) It remains a powerful explanatory tool, and in clinical practice and team working one finds that different approaches to risk are rooted in cultural practices.

Elliott’s review focuses on the environmental realm, but serves as a good and sceptical discussion of the more general focus of cultural theory of risk – and an introduction to what is sometimes a less than lucidly explained theory.

Can fMRI solve the mind-body problem? Tim Crane, “How We Can Be”, TLS, 24/05/17

In the current TLS, an excellent article by Tim Crane on neuroimaging, consciousness, and the mind-body problem. Many of my previous posts here related to this have endorsed a kind of mild neuro-scepticism, Crane begins his article by describing an experiment which should the literally expansive nature of neuroscience:

In 2006, Science published a remarkable piece of research by neuroscientists from Addenbrooke’s Hospital in Cambridge. By scanning the brain of a patient in a vegetative state, Adrian Owen and his colleagues found evidence of conscious awareness. Unlike a coma, the vegetative state is usually defined as one in which patients are awake – they can open their eyes and exhibit sleep-wake cycles – but lack any consciousness or awareness. To discover consciousness in the vegetative state would challenge, therefore, the basic understanding of the phenomenon.

The Addenbrooke’s patient was a twenty-three-year-old woman who had suffered traumatic brain injury in a traffic accident. Owen and his team set her various mental imagery tasks while she was in an MRI scanner. They asked her to imagine playing a game of tennis, and to imagine moving through her house, starting from the front door. When she was given the first task, significant neural activity was observed in one of the motor areas of the brain. When she was given the second, there was significant activity in the parahippocampal gyrus (a brain area responsible for scene recognition), the posterior parietal cortex (which represents planned movements and spatial reasoning) and the lateral premotor cortex (another area responsible for bodily motion). Amazingly, these patterns of neural responses were indistinguishable from those observed in healthy volunteers asked to perform exactly the same tasks in the scanner. Owen considered this to be strong evidence that the patient was, in some way, conscious. More specifically, he concluded that the patient’s “decision to cooperate with the authors by imagining particular tasks when asked to do so represents a clear act of intention, which confirmed beyond any doubt that she was consciously aware of herself and her surroundings”.

Owen’s discovery has an emotional force that one rarely finds in scientific research. The patients in the vegetative state resemble those with locked-in syndrome, a result of total (or near-total) paralysis. But locked-in patients can sometimes demonstrate their consciousness by moving (say) their eyelids to communicate (as described in Jean-Dominique Bauby’s harrowing and lyrical memoir, The Diving Bell and the Butterfly, 1997). But the vegetative state was considered, by contrast, to be a condition of complete unconsciousness. So to discover that someone in such a terrible condition might actually be consciously aware of what is going on around them, thinking and imagining things, is staggering. I have been at academic conferences where these results were described and the audience was visibly moved. One can only imagine the effect of the discovery on the families and loved ones of the patient.

Crane’s article is very far from a piece of messianic neurohype, but he also acknowledges the sheer power of this technology to expand our awareness of what it means to be conscious and human, and the clinical benefit that is not something to be sniffed at. But, it doesn’t solve the mind-body problem – it actually accentuates it:

Does the knowledge given by fMRI help us to answer Julie Powell’s question [essentially a restatement of the mind-body problem by a food writer]? The answer is clearly no. There is a piece of your brain that lights up when you talk and a piece that lights up when you walk: that is something we already knew, in broad outline. Of course it is of great theoretical significance for cognitive neuroscience to find out which bits do what; and as Owen’s work illustrates, it is also of massive clinical importance. But it doesn’t tell us anything about “how we can be”. The fact that different parts of your brain are responsible for different mental functions is something that scientists have known for decades, using evidence from lesions and other forms of brain damage, and in any case the very idea should not be surprising. FMRI technology does not solve the mind–body problem; if anything, it only brings it more clearly into relief.

Read the whole thing, as they say. It is a highly stimulating read, and also one which, while it points out the limits of neuroimaging as a way of solving the difficult problems of philosophy, gives the technology and the discipline behind it its due.

Less-than-busy doctors: “The Beetle Hunter” Arthur Conan Doyle

S J Perelman wrote a series of New Yorker articles titled “Cloudland Revisited”, wherein he re-read or re-watched various books and movies of his youth. In what now seems a slightly grating way , he invariably finds them ludicrous pulp. Anyhow, in “Doctor, What Big Green Eyes You Have”, Sax Rohmer’s Fu Manchu stories come in for the treatment. In this, Perelman writes:

“Petrie, I have travelled from Burma not in the interests of the British Government merely, but in the interest of the entire white race, and I honestly believe – though I pray I may be wrong – that its survival depends largely on the success of my mission.” Can Petrie, demands Smith, spare a few days from his medical duties for “the strangest business, I can promise you, that ever was recorded in fact or fiction”? He gets the expected answer: “I agreed readily enough for, unfortunately, my professional duties were not onerous.” The alacrity with which doctors of that epoch deserted their practice has never ceased to impress me. Holmes had only to crook his finger and Watson went bowling away in a four wheeler, leaving his patients to fend for themselves. If the foregoing is at all indicative, the mortality rate of London in the nineteen-hundreds must have been appalling.

 

My understanding is that Arthur Conan Doyle had a quiet career as a private ophthalmologist before literary work overtook his medical efforts. Of course, the structure of medicine as a career was very different then. The medical student and junior doctor of popular and popular-ish fiction tends to have more free time than is the norm nowadays.

Conan Doyle’s short story The Beetle Hunter is very much in this mould. Perhaps this paragraph reflects more about Conan Doyle’s own view of the medical professional than strictly being a piece of social history, but there you go:

I had just become a medical man, but I had not started in practice, and I lived in rooms in Gower Street. The street has been renumbered since then, but it was in the only house which has a bow-window, upon the left-hand side as you go down from the Metropolitan Station. A widow named Murchison kept the house at that time, and she had three medical students and one engineer as lodgers. I occupied the top room, which was the cheapest, but cheap as it was it was more than I could afford. My small resources were dwindling away, and every week it became more necessary that I should find something to do. Yet I was very unwilling to go into general practice, for my tastes were all in the direction of science, and especially of zoology, towards which I had always a strong leaning. I had almost given the fight up and resigned myself to being a medical drudge for life, when the turning-point of my struggles came in a very extraordinary way.

A story in which a recent medical graduate now is immersed in idleness would be seen as fatally implausible. He or she would be doing pro bono work down the lab, sequencing some beetle genome or other. Of course, this striving means we are Much Better People than those of long ago. Doesn’t it?

 

 

 

 

 

 

 

“Development is always going to destabilize a fragile balance of social forces.”

Via the work of John Adams, I have had some familiarity with the Douglas-Wildavsky Cultural Theory of Risk. Like this reviewer, I find the Douglas/Wildavksy treatment of environmentalism rather crude, while their overall cultural typology of risk stimulating. As the reviewer points out:

Most readers will be struck not by the abstract theory but by its application to the rise of environmentalism. This emphasis is unfortunate. The attempt to “explain” environmentalism makes a few good points, but on the whole this part of the book is crude, shortsighted, and snide. On the other hand, the sections that consider the relationship between risk and culture on a more fundamental level are sensitive and thoughtful.
Even at its best, Risk and Culture is not entirely successful at explaining the paradox of risk – the problem of managing the unknown – but parts of the book deserve to be read seriously by people interested in the problem of risk, including environmental lawyers.

 

I am now reading Mary Douglas directly, currently her Culture and Crises.: Understanding Risk and Resolution  Although she has a prose style that sometimes grates, and I am wary of possibly being unaware of technical anthropological issues that may be taken-for-granted, there is much to enjoy and think about.

Here is a brief quote from one essay – Traditional Culture, Let’s Here No More About It, which follows a passage about the occasional pitting against each other of development and “traditional culture” (usually, under western eyes, to the detriment of traditional culture):

Development is always going to destabilise a fragile balance of social forces. The people are understandably reluctant to do the gruelling hard work and accept the diversion of resources if the resulting prosperity will only line the pockets of outsiders. Furthermore, if it going to erode the community’s accumulated store of trust, and dissolve their traditional readiness to collaborate, the well-being of the community may be worse after development than before. There certainly is inherent ambiguity about the moral case. At least we can say that what stops development is not cultural traditionalism so much as the way it arrives, how it is organised.

This applies – in spades – to the many many “cultural change” / “transformation” etc projects that health services become the subject of. The suspicion that sacrifice and hard work on the part of staff will benefit only a narrow few (the Minister getting good headlines, various outside consultancies, higher management) surely underlies some at least of the cynicism about such projects that is undoubtedly prevalent.

 

Collective trauma and long term health impacts

On my other blog I have written about The Glamour of the West, an obscure book from 1928. One passage in this collection of episodic sketches deals with something I have have wondered about myself – the ultra long terms effects of collective trauma on the psyche. Of course, much tendentious stuff along these lines has been written, but I wonder about serious study of the topic:

Here’s the passage from Kelleher:

In the year 1928, when this book is being put together, there are many thousands of living Irish people whose parents were born in or about the Famine times. No wonder, here and there, if a melancholia should appear in the Irish. A generation born around the famine year could not escape the famine complex. In the west especially, life turned black with the black blighted potato. Social historians discuss the incidence of hysteria, and worse, due to the Zeppelin nights in London. The long duresse of the famine of 1847 was deeper shock to the whole population than any number of night-raids. Death might ensue from a bomb, but despair and death both were surer in Ireland. In Mayo the tragedy was at its height. At Westport workhouse, built to hold one thousand inmates, three thousand clamoured for entrance sometimes in a single day. Yet the pride of the Irish poor if well known; they will only enter the poorhouse when ruined and hopeless. The gate of the workhouse would be closed and barred early. Then the desperate, weak, lonely, agonised outcasts would throw themselves down to rest and snatch a sleep at the foot of the wall on the opposite side of the road. As many as seven corpses were found one morning like that, dead where they lay.

Here it is in the original (blurry photo and all) :