Marx and Lincoln
15th October 2003
Donald Sassoon (October) put some good questions to Karl Marx, but the old gentleman seems to be suffering from forgetfulness. In listing Bismarck, Lincoln, Gladstone and Disraeli as his enemies, he overlooked his letter of congratulation to Lincoln on his re-election in 1864. The letter, written on behalf of the International Working Men's Association, said: "The working men of Europe feel sure that, as the American war of independence initiated a new era of ascendancy for the middle class, so the American anti-slavery war will do for the working classes. They consider it an earnest of the epoch to come that it fell to the lot of Abraham Lincoln, the single-minded son of the working class, to lead his country through the matchless struggle for the rescue of an enchained race and the reconstruction of the social world." Of course, Marx isn't the only one suffering from amnesia. The Republican party has not at its recent national conventions arranged for the letter to be solemnly re-read.
Norman Birnbaum
Washington DC
Childcare politics
25th November 2003
Katharine Quarmby (November) offers an insightful analysis of the childcare situation in Britain. However, one of her points needs clarifying. She quotes me as saying: "The bad news for parents is that the same adverse effects of childcare [in the opening years of life on children's social behaviour] are there whether your child is there for a few hours or 40." This could be taken to mean that the degree to which children are adversely affected by being in child care will not vary with the number of hours for which a child is placed in care. This is not the case, as Quarmby's follow-up quote from me implies: "any reduction in hours will have a payoff, just as any increase will be bad." Whereas more time in childcare prior to starting school predicts higher levels of aggression and disobedience, less time spent in care predicts lower levels of such behaviour. There is one further - worrying - result that ought to be stressed. The adverse effects of lots of time spent in childcare emerged even when children were in high-quality programmes.
Jay Belsky
Birkbeck College
Dominant minorities
30th November 2003
Amy Chua's article (December) is accurate in its identification of economically dominant minorities as a major focus of tension in deprived societies but perhaps confused in describing them as "market-dominant." The reference to markets implies that wealth is gained through the operation of economic mechanisms. In fact, the means by which great wealth is gained are almost always at least partly political and where this wealth is concentrated in the hands of tightly defined family or ethnic groups it is unlikely that market mechanisms have played any great role. To describe white Zimbabweans as "market dominant" is like describing Normans in post-1066 England as "market dominant." This is not only a verbal quibble. To suggest that wealth is accumulated through the operation of impersonal mechanisms gives it an added legitimacy, at least as we tend to see things now. This explains why, for example, in the struggle between Putin and the oligarchs in Russia the western establishment instinctively takes the side of the oligarchs. Robert Cottrell's article in the same issue of Prospect illustrates this neatly. Cottrell is clearly aware that Mikhail Khodorkovsky gained his great wealth by political means, not by making and selling things that people wanted to buy. Yet, the fact that his power is embodied in financial form makes him "the most respected businessman in Russia."
We have long abandoned the idea that money pollutes and corrupts. We now seem to be moving to the opposite extreme, thinking that money cleanses and purifies. A person who uses force and fraud to gain political power is unacceptable. Someone who uses force and fraud to get money and then uses the money to buy power seems to be quite unobjectionable. Money is no longer something to be laundered; it is something that can launder its own origins.
Rory O'Kelly
Beckenham, Kent
British nursing 1
21st November 2003
Julia Magnet's compelling account (December) of being nursed in a London NHS hospital does not, alas, represent an isolated incident, as the rising number of complaints made about nurses to the health service ombudsman show. I agree with her that the problems associated with nursing in Britain are less to do with the recruitment and retention crisis (although that does play its part) than with an ideological shift in the culture of nursing that has moved the profession away from its caring foundations. As a consequence of government targets and the reduction in junior doctors' hours, registered nurses are being put under pressure to expand their practice away from nursing into medicine. Of course, many of these role changes have led to great advances in patient care. Yet, in this climate, it is all too easy to lose sight of the value of the traditional, professional nursing role, and what it is that makes nurses unique. "Low visibility" functions - such as forming relationships with patients, attending to hygiene and nutritional needs, listening and comforting - are in danger of becoming obsolete. But for patients, these are the most important aspects of the nursing role.
The problem for nursing, and thus patients, is that the government thinks that nursing can be carried out by unregulated support workers, thus further demeaning the professional value of caring. It has always been accepted that nursing has a good effect on patient satisfaction levels. However, in a world that only recognises measurable outcomes, proof of the effect of proper nursing care on patient outcomes is urgently needed. Unfortunately, this data does not exist in Britain.
Helen Scott
British Journal of Nursing
British nursing 2
29th November 2003
Julia Magnet's thoughts on nursing are poorly researched and reactionary. There are problems with the recruitment and status of nursing in the NHS. But Magnet's diagnosis of feminism and socialism as the diseases causing these symptoms is laughable.
The traditional nursing population of young white working and middle-class women is now able to choose better paid, better regarded and less stressful careers and, understandably, many do. Magnet believes a return to the 1950s is the required medicine. But would revisiting the stifling social and sexual politics of Britain in the 1950s that made possible the organisation of the nursing population at the time be palatable for her? It is not clear how we are to square her risible assertion that "nursing is about self-abnegation" with the powerful, assertive and feminist (with a small f) women who did, and do, lead nurses at ward level and elsewhere. For instance, the work of nurse specialists in challenging traditional NHS practices to improve the quality of patient care would be unthinkable in Magnet's nursing culture. To give only one example: brutal breast examinations carried out by unsupervised doctors are now largely a thing of the past. This is the result of the influence of patient-focused, nurse specialists responding to a vocal group of patients with legitimate concerns about their treatment. Magnet's reminiscences of sister dutifully reporting to doctor, and speaking when spoken to, fail to account for the complex decisions taken by nurses at the bedside and beyond. The myth of the innocent nurse who leaves work, crosses the street to the nurses' home, and spends her evening reading sewing magazines and chastely fantasising about dishy doctors is precisely that: a myth born of naive and one-dimensional assumptions about nurses, concealing illiberal cant about the relationship between social change and healthcare.
Jonathan Dowman
London SE5
British nursing 3
3rd December 2003
Julia Magnet's piece on the current crisis in nursing is accurate, perceptive and courageous. The "massive retreat" of nurses from the bedside (also described in the work of Janet Warren and Myles Harris) reflects the low status accorded to practical caring for vulnerable, uncomfortable and frightened people (all of us when we are seriously ill). Such caring, particularly in a high-tech environment, requires not only compassion, commitment, knowledge, and a huge range of skills, but a 360° solid angle alertness to patients' actual needs. I have been privileged to work with nurses who have these qualities and I know that they are undervalued - not least by the academic leaders of their profession.
Some of the factors behind the decline of nursing also threaten medicine. (See my Hippocratic Oaths: Medicine, the NHS and its Discontents, Atlantic Books, forthcoming.) Regulation, documentation, puerile targets and star ratings, innumerable directives and countless quality markers, will together reduce professionals to servile and rather dim box-tickers. Managerialism, rooted in distrust of professionals, is already having disastrous effects: less care is costing more. Independence, initiative and open-ended commitment to the patient is becoming a thing of the past. I hope Magnet's article prompts a wider debate, although I fear it will not.
Raymond C Tallis
Manchester
British nursing 4
25th November 2003
Julia Magnet's comment that modern nursing has tried to stamp out the idea of a "calling" hints at a possible contributor to the decline of the vocational ethic. "Called" by whom? In the middle of the last century and before, the answer in many cases was "by God" - and the belief was widespread enough for many who privately doubted it to behave as if they were so called. But in the 1950s, 40 per cent of Londoners were regular churchgoers; today the figure is 3 per cent.
Many people in past eras acted as if privately convinced there was a deity who would (or at any rate could) reward them in an afterlife. Thus low pay in this life was for many carers compensated by an afterlife incentive without which they would have cared for strangers less assiduously. In a modern society for which non-physical entities such as gods are implausible, and in which it is conventional, if a little unsettling, to believe that humans are ultimately a randomly evolved species standing on a ball spinning pointlessly through space, afterlife incentives do not exist. An impulse to care which is strong enough to override most other considerations then contracts to the individual's immediate "affective community" - relations, friends, and people known by name, connection and common history.
The contraction of affective community which flows from the decline of religion has practical effects in the day to day efficiency and culture of the caring professions. One cannot, of course, create plausible deities and afterlife incentives by political fiat - their time, in the developed world at least, has probably passed. But we do need to be aware of this aggregate psychological, and therefore cultural, change in order to develop compensatory mechanisms if the best of past care is to be replicated in the 21st century.
Heon Stevenson
Cambridge
