it tolls for thee

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328 ALFRED GELLHORN IT TOLLS FOR THEE PHILIP WOOD ARC Epidemiology Research Unit, Stopford Building, University of Manchester. Oxford Road. Manchester Ml3 9PT. England Alfred Gellhorn’s paper is a passionate restatement, in the context of some of today’s problems, of considerations raised by John Donne in his Devotions. Like his mentor, Gellhorn indicates for whom the bell tolls after having first identified that, however much the insularity of our attitudes may appear to assume the contrary, we are not entire of ourselves. Of course I am with him in the urgency of pleas for nuclear disarmament and progress towards a more equitable world. Who would deny propositions so self-evidently good and moral, at least in public? Had he been directing his passion and rhetoric to the population at large I would have been inhibited from response, not wishing to detract from his message. But the significance of his address is that he chose an emotive idiom when confronting a learned and essen- tially professional audience. He must have realized that this would render him vulnerable to scholarly scrutiny, and. it is in this vein I respond-albeit somewhat selectively. As both he and I are physicians, let me begin with a medical metaphor. He identifies a number of symptoms and physical signs-hunger, ignorance, ill-health and the exploitation of women, on the one hand, and proliferation of armaments, mal- distribution of resources and infant mortality on the other. Like any good doctor, he then attempts to construe these pieces of informaton to formulate a diagnosis. The basis of my critique is that he hasn’t elicited all the evidence, and he also neglects certain commonalities; he therefore reaches inadequate and inappropriate diagnostic conclusions and, in effect, becomes his own executioner. To switch metaphors, he knows which battle he’s fighting but he hasn’t appreciated the war of which this is only a part, and he therefore underestimates the enemy. I, too, would like to alleviate the symp- toms but, unless we seek out the underlying cause, our intervention can be expected to yield little more than palliation. Borrowing from the Little Red Book of Mao Zedong, we must identify the principal contradiction if we aspire to progress. . Sanitizing antinuclear protest My impromptu response when hearing the address delivered at Stirling was to pose a sociological question-why has nuclear proliferation become an issue that one can almost regard as being sanitized, considering the range of affiliations that have joined together to speak out in protest? By sanitized I mean not the tautology that it is concerned with maintain- ing health, but that it has become acceptable, and in many circles respectable, to articulate protest over this concern. It is a safe assumption that anyone reading this journal shares a concern for the health of the people. Equally, there must be few with the temerity to deny that a nuclear holocaust would inflict a mortal assault on the health of the populace in many parts of the world. But, although the omens give sore cause for increasing concern, the Apocalypse has not yet happened and, as Gellhorn concedes in relation to the ultimate weapon, predictions about the future remain one of the most fallible indulgences of our species. Let me hasten to add that I make the latter point not from any intention to dilute the force of the argument to which the auguries should give rise; for me the logic is compelling that action to reject the escalation is imperative. My perplexity stems from the fact that the threat of nuclear warfare has contingency status, relating to something that could well be around the corner. whereas poverty and starvation, and the uncertainty over survival these engender, are today’s problems rather than those looming for tomorrow. Although precise quantification and comparison are largely exercises in the imagination, the magnitude of the hazards appears to be of the same order. Why, then, have not the nuclear protesters united similarly and with equal urgency against the damage to health that is already and continuingly exacting its toll? Why confront the speculative and neglect what is before us now? My thesis is that, in seeking the answer to this enquiry, we have to penetrate to the roots of the problem. The quest requires that a number of different dimensions be taken into account, and I propose to discuss some of these. Security The heart of the problem can perhaps most easily be displayed by consideration of the word ‘security’. It signifies the condition of, or the means of, being secure (Shorter Oxford English Dictionary). Ety- mologically the latter term as a noun means simply ‘without care’, leading to its everyday sense of ‘free from fear or anxiety’ (which I shall refer to as sense No. 1). Among its other meanings are ‘free from risk as to continued or future possession of something’ (which I designate as No. 2) and, as a verb, ‘to safeguard from attack or molestation’ (No. 3). Now these senses differ appreciably in their con- notations. In general usage No. 1 is usually implied- and, as Gellhorn shows, much of the world lacks security today because of the threat from poverty and starvation. This is the substance of the criticism by deprived groups, when they dismiss nuclear protest as an expression by a fortunate middle class of fears to which it is otherwise unaccustomed; the Sword of Damocles has been poised over the ‘non-whites’ from time immemorial. In the context of national interests a more specific meaning is usually intended. No. 3. which is why the military immediately spring to mind. However, al- though the popular appeal of this reasoning tends to

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Page 1: It tolls for thee

328 ALFRED GELLHORN

IT TOLLS FOR THEE

PHILIP WOOD

ARC Epidemiology Research Unit, Stopford Building, University of Manchester. Oxford Road. Manchester Ml3 9PT. England

Alfred Gellhorn’s paper is a passionate restatement, in the context of some of today’s problems, of considerations raised by John Donne in his Devotions. Like his mentor, Gellhorn indicates for whom the bell tolls after having first identified that, however much the insularity of our attitudes may appear to assume the contrary, we are not entire of ourselves.

Of course I am with him in the urgency of pleas for nuclear disarmament and progress towards a more equitable world. Who would deny propositions so self-evidently good and moral, at least in public? Had he been directing his passion and rhetoric to the population at large I would have been inhibited from response, not wishing to detract from his message. But the significance of his address is that he chose an emotive idiom when confronting a learned and essen- tially professional audience. He must have realized that this would render him vulnerable to scholarly scrutiny, and. it is in this vein I respond-albeit somewhat selectively.

As both he and I are physicians, let me begin with a medical metaphor. He identifies a number of symptoms and physical signs-hunger, ignorance, ill-health and the exploitation of women, on the one hand, and proliferation of armaments, mal- distribution of resources and infant mortality on the other. Like any good doctor, he then attempts to construe these pieces of informaton to formulate a diagnosis. The basis of my critique is that he hasn’t elicited all the evidence, and he also neglects certain commonalities; he therefore reaches inadequate and inappropriate diagnostic conclusions and, in effect, becomes his own executioner.

To switch metaphors, he knows which battle he’s fighting but he hasn’t appreciated the war of which this is only a part, and he therefore underestimates the enemy. I, too, would like to alleviate the symp- toms but, unless we seek out the underlying cause, our intervention can be expected to yield little more than palliation. Borrowing from the Little Red Book of Mao Zedong, we must identify the principal contradiction if we aspire to progress. .

Sanitizing antinuclear protest

My impromptu response when hearing the address delivered at Stirling was to pose a sociological question-why has nuclear proliferation become an issue that one can almost regard as being sanitized, considering the range of affiliations that have joined together to speak out in protest? By sanitized I mean not the tautology that it is concerned with maintain- ing health, but that it has become acceptable, and in many circles respectable, to articulate protest over this concern.

It is a safe assumption that anyone reading this journal shares a concern for the health of the people. Equally, there must be few with the temerity to deny

that a nuclear holocaust would inflict a mortal assault on the health of the populace in many parts of the world. But, although the omens give sore cause for increasing concern, the Apocalypse has not yet happened and, as Gellhorn concedes in relation to the ultimate weapon, predictions about the future remain one of the most fallible indulgences of our species. Let me hasten to add that I make the latter point not from any intention to dilute the force of the argument to which the auguries should give rise; for me the logic is compelling that action to reject the escalation is imperative.

My perplexity stems from the fact that the threat of nuclear warfare has contingency status, relating to something that could well be around the corner. whereas poverty and starvation, and the uncertainty over survival these engender, are today’s problems rather than those looming for tomorrow. Although precise quantification and comparison are largely exercises in the imagination, the magnitude of the hazards appears to be of the same order. Why, then, have not the nuclear protesters united similarly and with equal urgency against the damage to health that is already and continuingly exacting its toll? Why confront the speculative and neglect what is before us now?

My thesis is that, in seeking the answer to this enquiry, we have to penetrate to the roots of the problem. The quest requires that a number of different dimensions be taken into account, and I propose to discuss some of these.

Security

The heart of the problem can perhaps most easily be displayed by consideration of the word ‘security’. It signifies the condition of, or the means of, being secure (Shorter Oxford English Dictionary). Ety- mologically the latter term as a noun means simply ‘without care’, leading to its everyday sense of ‘free from fear or anxiety’ (which I shall refer to as sense No. 1). Among its other meanings are ‘free from risk as to continued or future possession of something’ (which I designate as No. 2) and, as a verb, ‘to safeguard from attack or molestation’ (No. 3).

Now these senses differ appreciably in their con- notations. In general usage No. 1 is usually implied- and, as Gellhorn shows, much of the world lacks security today because of the threat from poverty and starvation. This is the substance of the criticism by deprived groups, when they dismiss nuclear protest as an expression by a fortunate middle class of fears to which it is otherwise unaccustomed; the Sword of Damocles has been poised over the ‘non-whites’ from time immemorial.

In the context of national interests a more specific meaning is usually intended. No. 3. which is why the military immediately spring to mind. However, al- though the popular appeal of this reasoning tends to

Page 2: It tolls for thee

National security and the health of people 329

invoke No. 1, the purpose of No. 3 is not usually to preserve universal freedom from anxiety and threat; how could it be, when this goal has not be-_n attained? Rather, it is more concerned with No. 2 and, more generally, with maintaining stability for the SIUIUS quo at any given time.

Unfortunately this is where the opportunity for distortion by Newsspeak and double-thi1.k arises. Although naive politicians may be genuine in their assertions of the need for security, the record of history makes it difficult to exonerate all of this breed from more sinister aims. The situation lends itself to cynical manipulation of ‘information’ by those with something to preserve-and that something is mainly wealth and the power and privilege that stem from such possession.

As Gellhorn documents, with military govern- ments the horrors are more often overt. These may appear to be essentially predemocratic societies, although one sees evidence of regression to such dynamics in the authoritarian posturing of ‘leaders’ of the ilk of Reagan and Thatcher. Democracy implies a shift in some elements of the balance, even if regression demonstrates that the contradictions are not escaped. The major source of power today is generally wealth. That itself, though, tends to be attractive only if it is not universally possessed, and its very manufacture (i.e. from surplus) depends on exploitation of others. Then its merchandizing re- quires further exploitation, and Gellhorn quotes Archbishop Rivera y Damas with a disturbing exam- ple of this.

Gellhorn pursues the origins of hunger, but with- Is it that national security depends ‘on armaments out really confronting that starvation is itself an and especially nuclear weapons’, or is there an under- offensive manifestation rather than the root cause. In lying economic imperative?-as was evident, for the process he implies that “the land and the market- example, in Germany between the two world wars. ing system are held by the few and. . those who To what extent are the war-lords responsible?-they work the land do not have control” in only some may well be little more than covert and at times parts of the world. This makes it necessary to try to unknowing tools (‘our know-nothing officials’) for burst the bubble of the Grand Illusion. However other interests. Does the manufacture of warheads much the rhetoric may try to persuade us to the represent a mania for destruction, as Gellhorn sug- contrary. Gellhorn’s description applies everywhere. gests, or is that perhaps just the perception of some- There is no country without an underclass and, as one who is reluctant or unable to recognize the significant moves to eliminate social stratification are rampant qualities of latter-day capitalism? Is not the nowhere evident, one can only infer that all societies truth evident through other manifestations, such as are dedicated to the preservation of inequality as the exploitation of countries of the Third World by source of power-be it based on wealth or, more promotion of tobacco products and aggressive ex- nominally, on ethnicity or the other issue Gellhorn portation of powdered milk for infants and of drugs identifies. gender. It should thus be clear that security superceded elsewhere because of their dangers-and means one thing to the privileged, and something by the manipulations of the World Bank, to which different for the masses. Gellhom refers?

Power ConJlict and fear

The reality is that a dialectic tension exists, between those wishing to hang on to and even enlarge their power and those aspiring to escape the shackles imposed by control. The tension is evident at various levels in society. Education offers an illuminating example. Its accepted purposes has been to transmit the values of the culture; in other words, to help promote stability or, more bluntly, to act as a mech- anism for inertia. More recently a repressive dimen- sion to this aim has been perceived, leading to reformulation of objectives with a greater emphasis on developing personal autonomy. Can the ex- ploitation of humans by their fellow beings be recon- ciled with such individual responsibility and liberty? One must presume not, considering the recurrent appearances of individuals like Senator McCarthy when changes seems to be in the air.

Gellhorn speaks of economic polarization and we seem to agree that this is not just between what he refers to as North and South, being evident as well in antagonism between constituent systems and coun- tries within the North. He hints at the power that is threatened in acknowledging that superpowers are being downgraded from bandmasters to components, although the economic basis is not made sufficiently explicit.

But what is the nature of this power people seek to retain? Foucault represents it as follows:

“Power is everywhere: not because it embraces everything, but because it comes from everywhere. power is not an institution. and not a structure; neither is it a certain strength we are endowed with; it is the name that one attributes lo a complex strategical situation in a particular society.’

This is where some of my themes intermingle, because the guise of security is used to increase the stranglehold of wealth even on allies. For example, multinationals like IBM intrude upon national legal autonomy with prohibitions about resale of their products even within the customer country. Informa- tion gathered supposedly for security purposes is also exploited for trade advantage through what can probably be regarded as unfair competition. On learning by these means of technological devel- opments by trading partners, it is not unknown for some countries to try to corner potential markets with their own less advanced products before the new technology can be manufactured for widespread sale; this has happened in some deals by U.S. firms with China.

In effect it is related largely to possession, although of course the nature of what is possessed changes at different stages of social development.

This is not intended as an anti-American diatribe. Rather, it comes from self-knowledge based on the predominantly past performance of the British em- pire. Surely, though, there can be no escaping the real

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330 ALFRED GELLHORN

nature of our economic systems, be these based on state monopoly or ‘free’ enterprise. When it comes to the crunch their morality cannot help but be corrupt, violating J. S. Mill’s precept that a man’s freedom can be infringed justifiably only to protect others; self- enrichment cannot be equated with self-protection, the vicious (though much lauded) competition within capitalist dynamics notwithstanding.

Although Gellhorn rightly stigmatizes the insidious transfer of responsibility to mindless technology, there is what amounts to a mindless quality to the logic of capitalism-and yet that is the music we step to. Its fundamentally non-benevolent nature is evinced by the relative disinterest in controlling scourges by preventing their occurrence. In 1981 the New England Journal of Medicine (304, 126129) estimated that the total cost of eradicating smallpox represented less than that of six hours’ expenditure on arms. The strictly economic gains from such exercises are appreciable, though unfortunately they are pea- nuts compared with the rake-off from more ‘classical’ economic exploitation.

The bidirectional nature of the polarization con- tributes to instability, but is by no means its sole cause. Another aspect concerns the fact that the countries manufacturing armaments have for most of the time been able to take their profits without themselves being threatened; in effect, they have exported the violence by providing the means for others. What Gellhorn does not explicitly confront, and yet which underpins the disinterest in nuclear protest by ‘minority’ groups, is that the scale of warfare is now such that it would spill over and affect the ‘non-involved’, and in particular the armaments producers. Thus the basis for trade-off has changed; the risks are now more immediate, and these give rise to fear.

Individualism

Thoreau, from whom I have already borrowed a phrase, wrote in the same passage

“Why should we be in such desperate haste to succeed and in such desperate enterprises? If a man does not keep pace with his companions, it is because he hears a different drummer”.

We are ageeed that the situation is desperate, but I must now take further issue with Gellhorn’s drummer.

The notion of democracy developed in the West and, although the country of its origin had a different theology, it was someone from a later expression of that culture, Paul, who reinforced the essentially individualistic orientation of a large part of Judaeo-Christian values. The further t-lowering of ideas of democracy took place more directly under the influence of those values. This individualistic emphasis contributes to the alienation that people from other and less fortunate parts of the world may feel about Western concerns, including nuclear proliferation-and perhaps especially so when they cannot help but see that capitalist exploitation hatched from the same nest.

It is interesting that this individualistic focus was part of the driving force behind the McCarthyite campaign, leading to the conclusion that it was better

to be dead than red. A moving refutation of this thesis had less wide currency because it was published as a letter to the Manchester Guardian; a Jewish refugee who had survived parts of the Nazi-inflicted horror had an unassailable argument when stating that, as long as death was evaded, there was still room for hope. Sadly, the proposition has become more questionable as we learn more of the aftermath of nuclear devastation.

Individualism in this context too often means freedom to exploit one’s fellows, or to expose them to danger in pursuit of one’s own gratification. This may not be so immediately evident in States’ Rights but, turning to a health-related issue, what else can account for the lack of a simple gun law in the United States? The value attached to the concept of individ- ual independence (what George Bernard Shaw re- garded as middle-class blasphemy) and claims for disability rights are fruits of the same set of values.

I stress this aspect not in order to be needlessly provocative, but in an attempt to establish a founda- tion for challenging Gellhorn’s view of the dynamics of change in Western societies, and of the role ecumenicalism might play in procuring what is de- sired. I wonder how he reconciles the implicit con- tradiction between the prevalence and nature of individualistic values in his society, and his own more mature recognition that we in fact exist in a state of subtle and complex interdependence. The correlates of individualistic thinking are also relevant, as I have indicated before (Sot. Sci. Med. 16, 1387-1388, 1982). One is an abhorrence of utilitarian values, which can help to obscure both etiological enquiry and the identification of directions for remedial action.

Gellhorn’s understandable aspiration is that tough-minded people can make history, but he formulates this idea grounded in the illusions of American democracy-with its notions of pluralism and the idea that the influences of pressure groups and the like will balance out. I agree that stratification has to be combatted and eliminated, but this is unlikely to come about unless we challenge what thrives on its existence. A now-discredited political leader in the U.K. won an election with his stated purpose of scaling and taking control of the commanding heights of the economy: his analysis of the need was sound but, like many others, he failed to realize his intentions.

Citizen organizations are an important means of articulating protest, and we must lend every strength to their arms. However, pure reason will not suffice because our world is neither rational nor just-to which the popular support for doctrinaire and dan- gerous brinkpersons like Reagan and Thatcher (to confine myself to our own ‘camp’) surely attest. This is what I regard as the fundamental weakness of worthy but rather woolly liberalism, with its appeals to sharing and enlightenment (vide the Brandt Com- mission); it fails to acknowledge the essence of the obstacles, If we are to bring about changes in our social dynamics we shall have to explore other means, but Gellhorn does not acknowledge this.

On two other aspects I have equally serious doubts. The consequences of worthy acts, such as the dona- tion of grain by the Amish. are not necessarily as

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National security and

unquestionably good as they may at first appear to be, certainly if complementary action is not taken at the same time. In many ways such initiatives are not unlike what Gellhorn admits in regard to the accom- plishments of medicine, rather like Band-Aids that patch things over-often in such a way as to help prolong the problem. Secondly, the churches include countless upright individuals, and as organizations they have at times been in the van of progress. Too often, though. their record has resembled that of education, as a prop for the establishment (e.g. the drumhead service, and Peter’s reinforcement of the subjugation of women); I therefore cannot have much confidence in the ecumenical movement on its own unless it begins to carve a new path of civil protest.

The role of medicine

My final aim is to bring these threads together in the context of Gellhorn’s benevolent view of medi- cine. He asserts as a “fundamental fact that medicine is a social science”, an observation I would challenge. First, it is necessary to distinguish between medicine and medical science, the former being a profession that is practised and which, in such pursuit, exploits concepts drawn from medical and other sciences but which is itself more akin to a field of technology.

Secondly, the denominator of concern in the prac- tice of medicine is not the group, with which by definition the social sciences are exercised. Clinical professions focus almost exclusively on individuals, a fact not unrelated to their preoccupation with cure at the expense of prevention. Moreover, the claim to be socially oriented rings rather hollow in the face of widespread feelings of neglect in regard to caring functions, particularly evident in those who have to come to terms with chronic illness.

the health of people 331

Thirdly, the individualistic focus has material im- plications. Historically the basis of the relationship between patient and physician is one of contract, with all the entrepreneurial overtones that this entails- and hence a degree of more direct involvement in the economic system. However, this offers only a partial explanation for the customarily conservative atti- tudes of physicians. Doctors have also been accorded positions of considerable respect and privilege, and it is only natural that they would take whatever actions might be seen as necessary to preserve their status and hence also safeguard the stability of current arrange- ments.

Gellhorn also suggests that “primary health care is what . . doctors have been doing for millenia”. This, too, I would dispute, and my remarks on the basis of medical practice are germane to the point. Certainly the client delegates something to the professional, which confers power upon the latter. That can then be used for what amount to restrictive practices, and it was to breach these that the programme for primary health care (PHC) was launched. Primary medical care is far from being the same as PHC, and the latter is much concerned with a renegotiation of power-restoration of autonomy to those from whom it had been expropriated.

Envoi

My critique is vulnerable because it does not indicate constructive alternatives to the weaknesses I have tried to display. This leads me to close by echoing what Wystan Auden wrote in “Age of Anxiety”:

“We would rather be ruined than changed. We would rather die in our dread than climb the cross of the moment and see our illusions die”.

REJOINDER

After reading the comments, it is apparent that the issues which I raised touched deep areas of sensitivity for many of the discussers. It was the issues suggested by my paper, I think, more than how I described them or what I suggested could or should be done, which captured the attention and thoughts of the commentators. So vehement were some of the reac- tions that it seemed to me that sometimes I was being castigated for having said just what the discussor thought I should have said. In any event, I was stimulated by the responses and appreciative of the consideration given to the concerns which I expressed to the Conference.

Professor Navarro agreed, I believe, with the identification of issues which I wished to relate to national and international security, that is, the nu- clear arms race, the international armament sales to the developing world and the associated militarism, the widening gap between the haves and have nots manifested by hunger. ill health, illiteracy, deepening poverty and disparities for women, but he finds my efforts to characterize our role as citizens ill- conceived and ineffective.

Professor Navarro believes that the ills of the world ranging from local to the global setting are prin- cipally manifestations of the struggle between a rich and powerful class and the vast underclass. If Pro- fessor Navarro feels that the system can only be changed by revolution, then I disagree. I favour change by evolution, which I believe can occur and has occurred and I was calling on the social scientists to be among the agents for such change.

Professor Smith found more in my paper with which to agree than disagree, and I am grateful for his comments. His major criticism is on my emphasis of the role of private citizens and citizen groups. He very properly points out that government is quick to shift its responsibilities to the private sector and Professor Smith deplores this. It is my belief, how- ever, that citizens working on social issues are more likely to monitor government activities with sophistication and effectiveness. Also, it is more often the private sector which has greater flexibility in devising new approaches to social problems or in identifying new issues which should be addressed by government.