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This is why I hate intellectuals

Tag: health

Policy break: maternal mortality

policy

One of the most encouraging things to happen in recent American political discourse is the new and heightened focus on racial disparities in maternal mortality rates. Black women are three to four times more likely to die in childbirth than white women – and this is a scandal, and needs to be seen as such. It’s a cruel and senseless world in which creating new life can carry a death sentence, and this does not need to be happening. Every preventable death that takes place in a maternity ward – and up to 60% of these are preventable – is a woman who was, objectively, murdered by a social order that fails to allow the essential needs of human life to be met. It has to end. How?

One popular approach comes from Senator Kamala Harris, also running for the US Presidency. Her Maternal CARE Act explicitly aims to eliminate this racial disparity through three proposals: providing funds to ‘incentivise’ healthcare providers to deliver ‘integrated health care services to pregnant women,’ providing competitive grants to encourage medical and nursing schools to introduce implicit bias training, and directing the National Academy of Medicine to make recommendations on a further rollout of implicit bias training as part of medical education. Of these three, the proposals concerning implicit bias have received by far the most emphasis, from both Harris and the media. It’s a popular policy, and it’s already being woven into Harris’s Presidential campaign.

It’s the other proposal, however, that has the greatest chance of offering a potential solution. The racial pregnancy outcomes gap is not fixed or universal: in most of the United States, the gap is widening – but one US state, North Carolina, has managed to almost entirely close the gap. Black women died during childbirth at a rate of 24.3 per 100,000 in 2013, down from nearly 60 in the early 2000s; white women at a rate of 24.2. Some of this narrowing is accounted for by a rise in white mortality, which more than doubled in the same time period. I don’t think there should be any question that it would be far better, if it were the only option, to reduce the total number of preventable deaths while maintaining a racial disparity (North Carolina is 71% white). But the rise in white mortality is in line with a nationwide collapse in quality of life for white working-class individuals (the national rate climbed, while the decline in black mortality, in both relative and absolute terms, is unique. One significant factor is the state’s Pregnancy Medical Home programme, which uses the existing Medicaid system to deliver state funds that promote early intervention for high-risk pregnancies. The programme is expansive, addressing not only strictly medical issues but factors such as homelessness or food insecurity that strongly correlate with deaths during childbirth. It shows concretely that policy aimed at improving the lives of the working class can massively alter racial disparities. The most shocking and deadly effects of racism really can simply vanish once an effort is made to redress inequality in general.

The programme is, of course, deeply insufficient. It’s brought mortality rates for black women in North Carolina down to around the level of the national average, which is still monstrously high. But it shows the kind of outcomes that could emerge out of more radical intervention. Currently, the programme offers women advice and assistance dealing with food insecurity and homelessness – what if there were a serious redistributive programme to eliminate these factors altogether? In New York City, 63% of white patients give birth in the safest hospitals in the city; for black women, it’s 23%. What if no hospitals were unsafe? This is why the question of race and childbirth mortality is so crucial: as soon as you get really serious about solving it, you start dealing with the totality of oppression in general. After all, isn’t the question, at its root, that of life itself?

Senator Harris is seemingly not interested in confronting that question. It proposes a demonstration project, in which ten states would, for a limited period, mimic the South Carolina model. When compared with more ambitious policies, such as Medicare for All, it’s simply not enough. But the flagship proposal has nothing o do with increasing the quantity of care available: the radical element, the part that stands out, is the implicit bias training.

Implicit bias theorises that behaviour is influenced by unconscious stereotypes – that, for instance, even an avowed and conscientious anti-racist might hold racist attitudes and adhere to stereotypes, even as they explicitly reject them. In this context, the implication is that the unconscious biases of medical workers lead them to deliver a worse standard of care to black patients – because black suffering is simply not valued as much as white suffering. Implicit bias training aims to overcome this effect. First, trainees typically take an electronic implicit bias test, in which they’re asked to associate names or terms with the categories ‘white or pleasant,’ or ‘black or unpleasant,’ or ‘white or unpleasant’ or ‘black or pleasant.’ Their response times are measured. Typically 70% of participants (including nearly 50% of black Americans) have a harder time associating positive terms with the ‘black or pleasant’ category than the white. This gives a numerically quantifiable indicator of the test subject’s unconscious racism. They’re then trained to recognise this bias, confront it, own up to it, and overcome it. Then, the test is administered again, to see if they’ve improved.

One of the more alarming problems with implicit bias training is that it doesn’t work. Studies of the literature have found that the correlation between implicit bias test scores and actual discrimination outcomes is ‘close to zero.’ Systemic racism is not the same as the aggregate of millions of unconscious ideas, and the unconscious mind moves in stranger ways than causing you to hesitate on a timed computer test. Worse still, it’s been suggested that implicit bias trainings can have an effect – in the wrong direction. An exhaustive training in the persistence of racial biases can, it seem, have a mimetic effect. The sessions might encourage, not alleviate, racial stereotypes.

This is of minor importance when it comes to implicit bias training in universities or the corporate sector – even if it really is counter-productive, that doesn’t affect its primary purpose as a PR fig-leaf. But if you believe, as Senator Harris appears to, that the disparity in health outcomes is caused to some degree by unconscious bias, the consequences here are potentially monstrous. Outside of the ten states selected for the Pregnancy Medical Home demonstration project, her proposal could directly lead to a widening of the racial disparity, and more black women dying during childbirth.

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All this assumes, of course, a certain vision of what policy is: we have a society that’s mostly good, but which has some problems, and after reviewing the evidence we can decide to do things that might fix those problems and help society function better and more equitably. I happen to have another view, and try to be as resistant to facts and evidence as possible. The sphere of potential is vast – and policy is a dream we have about ourselves, the kind of people we think we are, the kind of world we think we live in. This is why the argument that Trump’s wall wouldn’t be very effective at keeping out undocumented migrants is itself so singularly ineffective: Trump’s base don’t want a wall because they’re convinced it will lead to desirable objective outcomes. They want a wall; they want to live in a country that’s fortified.

But Harris and her ideological kin are very much wedded to the utilitarian and technocratic approach. See, for instance, her most notorious policy innovation: her practice, as a California District Attorney, of throwing the parents of truant children in jail. This is, as critics have pointed out, a profoundly unpleasant thing to be doing – but her campaign defended it in explicitly technocratic terms. ‘A critical way to keep kids out of jail when they’re older,’ a spokesperson said, ‘is to keep them in school when they’re young.’ Her contention is that the policy worked – school attendance rose in San Francisco during her tenure as DA – and there’s therefore nothing to complain about. The ends (kids in education) justifies the means (intensified police surveillance and discipline of the working classes) – so long as it’s effective. So why, then, is she now proposing policies which are so profoundly unlikely to advance their stated aims?

The Maternal CARE Act is incomprehensible when evaluated according to her own criteria. Under a different set, it makes a lot more sense. The findings that this procedure fails to achieve its intended result shouldn’t really be counter-intuitive: DARE doesn’t stop kids taking drugs either, and few social problems are attributable to people not being berated or lectured to enough. If these procedures have proliferated, to the extent that elements of the State now want to introduce them in legislation, it’s because their actual purpose is something very different. These are mandatory sessions in which workers are castigated for their shortcomings, told they’re responsible for some of the worst evils of the world, and subjected to hyper-surveillance and discipline as a corrective measure. It’s an upwards redistribution of power, a Taylorism for the reflexes, the assimilation of not just the conscious self but of hazy unconscious attitudes to the sovereignty of the administrative class. If the central question of policy is that of the kind of world we want to live in, the image painted here is bleak. A world of faulty machines. A world in which people are constantly being dragged down by their own evil natures, and have to be improved by an enlightened elite with its dictatorship of prods and nudges. A world in which the solution to what causes us to suffer isn’t shared struggle based around shared needs, but the same atomised self-negation that constitutes much of that suffering.

That Harris and her supporters so badly want implicit bias to be the problem, and this mode of surveillance and control to be the solution, is instructive. The desire is far stronger than their fetish for rationality or evidence; technocracy has far more to do with power itself than efficiency, outcomes, or the actual expertise of the knowledge-monopolising classes. (In the first wave of Taylorism, the savings made by firms through increased industrial efficiency were entirely swallowed up by the costs incurred by the new administrative classes.) This example can, I think, shed some further light on Harris’s truancy policy. The point wasn’t to improve school attendance by any means necessary – it was to impose state discipline, using any excuse available. It should be clear that the anti-racism in these purely managerial articulations of anti-racist politics is hollowed out and infinitely deployable. After all, Senator Harris seems willing to let black women die, if it means she gets to tell other people how it’s all their fault.

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How to overthrow your own body

Pictured: Gold medallist, men’s 750,000 metre coup

Human language had a good run, but it’s about time to admit that the whole experiment has ended in failure. For two hundred thousand years we’ve been flapping mouths and breathing spittle at each other in a supposedly meaningful manner. We’ve invented needlessly complex processes for immortalising these self-important eructations, first on rock, then paper, then computers. It’s hard to calculate exactly how much this habit of language has cost us over the centuries, but it could only run into the tens of trillions of dollars. All those cuneiform temple inscriptions, all those public speaking engagements, all those shitty radio panel shows – and for what? The whole system has proven itself so useless that we feel the need to periodically massacre each other for attaching the wrong meanings to the wrong set of belches. This still goes on today, despite the fact that it’s now well known that words can never really refer to things but only to other words. Language is the hideous bastard hatchling of a hydra and and an ouruborus, and it needs to be slain immediately. If any further evidence of this is needed, you only have to look at the official readout of Obama’s phone call with Putin concerning the Russian intervention in Crimea.

The degeneration of language is happening at a frightening pace. Nothing in Obama’s ninety-minute conversation makes any sense. The phrase ‘going forward’ (a ghastly coinage bordering on the eldritch, one that’s apparently supposed to convey an energetic dynamism but only summons the image of some unfortunate person drowning in an office cubicle as it slowly fills with printouts of pie charts) appears twice in the space of four sentences. Obama talks about the Budapest Memorandum and the Helsinki Final Act and the Organisation for Security and Cooperation in Europe; he sounds like a dorkily enthusiastic teenager getting a bit too wrapped up in his performance at a Model UN conference. He hints at sanctions, as if half of Europe weren’t dependent on Russian gas. It’s a twisted parody. Language is, before anything else, a vector of deception. The United States government has broken all the agreements he mentioned, reneging on its promise not to extend NATO up to Russia’s borders, helping prompt and direct the nationalist revolution that overthrew Yanukovych, engaging in wars of aggression across the globe. More fundamentally, he’s pretending that he and Putin are something other than what they are: a pair of bureaucrats instead of two bloodstained warlords, each of whom could, if the fancy took them, kill every single human being on the planet several times over. There’s no record of Putin’s response to Obama’s extended series of laryngal honks, but you get the impression that he’s gently humouring this earnest American who doesn’t seem to understand the way the world actually works, playing along in his game of talking about other words rather than things. It’s a shame, because for a while Putin looked like the only person who could save language from itself. In 2008, as Russian tanks were comprehensively fucking the Georgian army, he declared his intent to ‘hang [Georgian President] Saakashvili by his balls.’ This is what linguists call a speech act, doing by saying; precisely through abandoning the principle of representation it’s the closest words can come to being about things.

There aren’t many speech acts in the current crisis. We’re beyond the point where we can meaningfully distinguish between words and deeds. The Russian intervention in Crimea is intended to send a message to the new government in Kiev and its backers in Brussels and Washington; action has become infected with the sordid ephemerality of language.

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In the end, this whole mess can be blamed on the Sochi Winter Olympics. It’s a well-known and boring fact that in ancient Greece, wars were put on hold for the duration of the Games. The idea of doing the same thing now isn’t just infeasible but nonsensical; war and the Olympics are one and the same thing. Host governments treat the Games in much the same way that they treat foreign wars: they provide a chance to issue some contracts and boost important industries, they let you redraw the maps (turning a beach town into a mountain resort, or a moulding industrial park into a germ for gentrification), they’re a matter of national pride and a propaganda vehicle that helps calm internal contradictions – but at the same time they never seem to deliver the profits they promise; the costs inevitably spiral, and afterwards they tend to leave cities full of half-ruined buildings. It’s not just a matter of resemblance. With their vast crowds and attending dignitaries they’re a deliberate target for terrorists, allowing the hosts to show off their various defence technologies to the world. London 2012 wasn’t much more than an enormous arms fair, with an aircraft carrier on the Thames and missile batteries on the roofs of homes. Russia in particular seems to like conducting its imperial adventures during the Games. While jets battered Stalin’s birthplace in Georgia, representatives from the two countries were playing beach volleyball in Beijing. The Ukrainian paralympic team is still in Sochi. All this isn’t a distraction from the sport; it’s another facet of the same phenomenon.

Of course, sport is fascist bullshit. Liberal critics of organised sport like to hone in on its aggression and competition and the absurd salaries paid out to its practitioners, but none of this is the real problem. It’s true that most Olympic sports are some kind of symbolic warfare (with the potential exception of figure skating, although there’s still a case to be made against it), but a tendency towards aggression and competition is only a secondary characteristic of the fascist cosmology. The fundamental fascist vision is one of a cohesive and organic society, a society structured around the metaphor of the healthy body. Any politics of the body will by necessity be a politics that acts on the body: the healthy body becomes a regulative ideal, and images of healthy smiling men marching off to the front are suddenly everywhere. This spectacularisation of the body is always present (millions of people watch the Olympics), but it’s always also accompanied by the idea that health is good in and of itself, beyond any relation to the aesthetic. Individual health means social health. In Russia, the connection between the healthy body and militarism is still very much alive; Putin himself is constantly taking his shirt off to ride horses, wrestle tigers, catch fish, and otherwise demonstrate his unparalleled dominion over the animal world. In Western countries we generally prefer to wage war through silent and terrifying robots of death, but as the population grows steadily more obese and work is increasingly an activity that takes place in front of a screen (a screen showing sales figures, a screen showing a Pakistani village about to be obliterated, it makes no difference), the issue of health becomes a matter of deep general concern. And, as everyone knows, the best way to become healthy is through sport. Sport isn’t dangerous because it encourages competition or tribalism; it’s dangerous precisely because it’s healthy.

If there’s a central fascist procedure, it’s the subsumption rather than the sublimation of contradictions. Class antagonisms are buried in the organic nation, internal difference is either consumed or ejected, all cracks are papered up. The healthy body is a prime example of this. The ideology of sport and fitness has its roots in Victorian England – muscular Christianity, artificial famines in Ireland and India, the desperate belief that sports will prevent masturbation – but while it reached a kind of apex in the historical Fascism of the twentieth century, it stubbornly refused to die with its host. Left-wing responses to all this nonsense have been sadly anaemic. The most popular is a kind of body-euphoric self-affirmationism: the idea is that we should embrace all bodies as healthy and all bodies as beautiful. This appears to be a response to the dominant cult of fitness, but really it’s a capitulation to it and a failure to challenge its terms. Fitness and beauty are still good, sickness and ugliness are still bad, but the latter two are shoved beyond some metaphysical horizon. Instead of embracing ugliness in ugliness and as ugliness, its very existence is denied.

The figure of the body is a central concern of poststructuralist theory, and the academic tendency to refer to people as ‘bodies’ (based on the idea that the person is a fictive construct – after all, the word itself derives from the Latin persona, or mask – and that the only thing we can safely say about someone is that they have a body) seems to have filtered into a lot of non-academic discourse. At the same time the body itself is often instrumentalised rather than examined; this is why there’s so little real resistance to fitness fascism. It’s there from Foucault. In Nietzsche, Genealogy, History, he writes: The body is the inscribed surface of events […] and a volume in perpetual disintegration. [Our] task is to expose a body totally imprinted by history and the process of history’s destruction of the body. Foucault seems to have a blind spot when it comes to the body; his approach to it is surprisingly un-Foucauldian. Genealogy opposes itself to the search for ‘origins,’ but when Foucault discusses the body as a site of scarring and crumbling, he implies the existence of an originary unscarred and unimprinted body; a body that’s perfect and primordial and pristine. There’s no such thing: a newborn baby is bloodied and screaming. It’s necessary to admit that there is no primordial unitary body, that the thing we call the body is nothing more than the collection of scars that constitutes our experience of it. There’s only a series of metamorphoses without aim or origin, and the healthy body is only another kind of deformation.

The overthrow of the body is a matter of urgency, because things aren’t going well. The new Ukrainian government includes six ministers from the neofascist Svoboda party. Russian soldiers are surrounding military bases in Crimea. The year ends in fourteen, idiots are in charge across Europe, and two global alliance systems are squaring off as Slavic nationalists do their best to rile up a great power. In the end it’s about language, the filthy habit of humanity. If your throat coughs up a hard g sound like a Russian then you’re shunted to one side, if you wheeze an h like a Ukrainian you’re on the other. The shame that periodically surrounds the body tends to be centred on shitting and pissing and fucking, because these acts remind us that the body isn’t a unitary entity closed off from its environment; really it’s speech that’s disgusting, because it lets us pretend that it is. The idea of an organic and discrete Ukraine and an organic and discrete Russia is dependent on the metaphor of an organic and discrete body. Irredentism echoes Foucault: history has effected a crumbling-away of the national body, but rather than just uncovering this body they want to restore it. The mad advocates of health and fitness have nuclear weapons at their disposal. If humanity is to survive the coming century, we all need to start smoking heavily.

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