Upton-on-line Diaspora Edition – Feb. 9th 2004

In this issue

Alain Juppé stars as a martyr in his very own political drama, more on the veil, and three books reviewed from the burgeoning academic industry in analysing health reforms.

But first, some verbal wreckage from NASA. How many u-o-l readers gagged when the mission head for the recent Mars landings talked breathlessly of the first images from Opportunity as revealing "a bizarre alien landscape". Bizarre? Alien? What was he expecting? Neatly trimmed suburban berms, newly painted letter boxes and fire hydrants marked by no parking zones? Upton-on-line thought the images looked - well, rather Martian and vaguely reminiscent of parts of New Mexico.

Martyrdom in the secular state

After all the effort that is being put into removing visible signs of religious observance in schools you might think France was a place in which blind faith and sacrifice in public life might be frowned upon. Not a bit of it. French political life is conducted with all the drama of a passion play. And no event has been as riveting as the recent martyrdom of Alain Juppé. This secular road to Calvary has been a show stopper. Convicted on charges of having used public money to employ party officials (when Treasurer of the city of Paris a decade ago), M Juppé has found himself engulfed in eulogies and desperate entreaties that he should remain in public life. The President, Jacques Chirac, the Prime Minister, Jean-Pierre Raffarin, and just about every notable on the French right joined the chorus. His arch competitor Nicolas Sarkozy was forced to pronounce his solidarity.

Given that the penalty handed down included a 10 year suspension from holding public office, it was not entirely within M Juppé's power to oblige. But since the mere lodging of an appeal suspended the sentence, M Juppé nobly decided to lodge one thereby continuing in his many offices (Mayor of Bordeaux, President of the newly formed political party of the centre-right, the UMP, and Parliamentary Deputy) like some latter day penitent in search of absolution. Conviction (of the judicial variety) and canonisation, all in the same rich human drama. Rarely have sackcloth and ashes been so nobly worn.

All of which is incomprehensible to dwellers in the anglosphere. Upton-on-line has yet to meet an Anglo-Saxon (or for that matter a Nordic) who is not reeling in disbelief from the way in which the French political establishment has reacted. Consider the case of Peter Mandelson, Blair's Juppé, hounded from office before anything was proved and still out of office despite being absolved on the charges levelled at him. The Tory opposition howled for blood and got it. Not so across la Manche. Human nature is much bigger-spirited - slow to chide and swift to bless. The Left has been muted in its reaction. Juppé's alter ego on the left, Laurent Fabius, has spoken of the essential human integrity of Juppé's decision. Delighted that the courts have eliminated President Chirac's most beloved political son and heir (he is widely termed the Dauphin, the title formerly reserved for heirs to the French throne), many socialists have been able to tut tut about the human side of the tragedy.

Only the crotchety old bad fairy of French politics, the National Front leader Jean-Marie Le Pen, has been unkind enough to remind everyone that M Juppé himself had pledged to retire from political office if found guilty, and ungalant enough to opine that the conviction removes the last veil between the scandals at the town hall and M Chirac himself who was none other than Mayor of Paris at the time the corrupt practices were in full swing.

The few figures to speak out in favour of the judicial process have sounded distinctly beleaguered. The president of the magistrate's union, M Dominique Barella, noted forlornly that "the affair shows that France remains a developing country in terms of its democracy when its politicians haven't yet adjusted psychologically to the idea of the independence of the judicial system". That didn't stop M Chirac from talking of Juppé as a man possessed of exceptional "competence, humanity and honesty", and the Prime Minister from expressing his "surprise". (Questioned in Parliament, he went to considerable lengths to explain, dictionary in hand, that his use of the word surprise only indicated a state of mind and was in no way the expression of "an opinion or a judgement and even less a judgement on the Judgement".) Others were less scrupulous, variously describing the conviction as disproportionate, hypocritical, grotesque and brutal! No-one seemed too troubled by the exasperated reminder from a former judge (who had himself resigned after failing to arraign M Chirac) that all of these expostulations themselves risked being in breach of the law for trying undermine the authority and independence of the courts.

What everyone knew

The case seemed clear enough. The court listened to a dozen or so members of M Juppé's team explain, one after another, that - mirabile dictu - none of them had known what was going on. Somehow, over a million euros worth of salaries were snaffled for party political operatives without anyone realising. The court couldn't bring itself to swallow this which was scarcely surprising when one of M Juppé's aids had stated bluntly that "everyone knew" what was going on. So the court applied the law - exactly as had been foreseen when it was passed in 1994. And the Government in power then was none other than the same centre right that is in power today. The newly martyred M Juppé was Minister of Foreign Affairs at the time. The provision in question was passed without a dissenting voice. Apparently it had never been conceived that the law could apply to the people who were passing it. How else to account for the wave of disbelief and horror?

The most plausible reason - but one that no French politician seems capable of uttering - is that M Juppé is something of a sacrificial lamb. Despite having an 'image' problem (he is regarded as too clinical, technocratic and hyper-competent, and insufficiently empathetic), no-one doubts that Juppé is a hard worker and a man of honour. He had the misfortune to have presided over the dying days of a system which everyone acknowledges had gone on for years no matter who was in power. Funding political parties through illegal contributions was the way it was done. M Juppé, since his conviction, has come to the verge of admitting as much. So the outpouring of emotion from colleagues is, one senses, an admission that they should all have joined him in the dock. Upton-on-line can't help but feel a certain sympathy for his plight - nor deny the dignified way in which he has seen, to use his words, the sky fall on his head.

Which makes one wonder why, if this was the case, the National Assembly that passed the tough anti-corruption law back in 1995 hadn't drawn a line under the past and conferred a retrospective pardon on the deeds of the past. Apparently this was regarded as just too hot at the time. But the temptation for the political establishment to do what it probably wished to do back in 1995 and draw a retrospective line across the past to save M Juppé must, like Satan in the passion play, be gnawing away in more than a few minds. Not least the President's, since the only thing that has prevented his being dragged into the courts on similar charges is constitutional immunity from prosecution whilst in office. As Le Monde unpatriotically noted in the wake of the Juppé affair, no fewer than half a dozen judicial tracks lead to the President's door - all of them stopped as long as he remains in office. With M Juppé potentially barred from succeeding him the President may himself have to strike out upon the martyr's path and nobly stand a third time for the presidency.

Perhaps the sanest note was struck by a senator, one Henri Weber, who took it upon himself to express the startling concern that there was a worrying "gulf between the [political] microcosm and the country at large which wants to see the law applied to all from the most powerful to the most humble." Upton-on-line doesn't know anything of Senator Weber's background but it sounds mightily protestant and grimly Anglo-Saxon.

A footnote on veils

Readers of the upton-on-line pre-Christmas bumper special issue on veils will be thrilled to learn that the legislation banning religious emblems in schools has been introduced into the Assemblée Nationale. The text is exquisitely nuanced. Banning clothes and emblems that were a visible manifestation of religious observance was judged too crude. On the other hand a ban on ostentatious manifestations seemed too subjective. So the Government alighted upon the word ostensible. In case the blinding clarity of this formula is not immediately apparent, the proposed law defines an ostensible sign as one that is worn so as to make its religious significance immediately recognisable. Upton-on-line can imagine all sorts of try-ons from citizens wearing veils with Mickey Mouse designs or kippas cunningly and rakishly got up in French national colours (what could be more patriotic?).

This is not as unlikely as it may appear because the authorities have let it be known that the good citizens of Mayotte (a far-flung part of the French cultural exception in the west Indian Ocean) will be exempt. The female citizenry (the collective noun is Mahoraises) are 95% Moslem and have a penchant for decking themselves out in something called the kichali. This bandana look-alike apparently has nothing to do with religion but constitutes a 'cultural choice'. So it's only religion that can disturb the serenity and neutrality of the school playground - not culture! Not that these youngsters miss out on religion - most attend Khoranic schools in the morning and then receive a secular antidote at the state school in the afternoon.

Finally, and most interestingly, has been the reported reaction of Moslems outside of France. At the height of the recent Iraq war France's stakes could not have been higher. President Chirac's welcome in Algeria last year involved ecstatic scenes that western leaders can normally only dream of. But with the banning of veils in schools, French prestige in North Africa has come down to earth with a bit of a bump. And in a most surprising way. For as Olivier Roy, interviewed recently by Le Monde, pointed out, reaction against France is coming not so much from wizened old mullahs but young, emancipated women in cities like Beirut and Cairo. These same young women are, at one and the same time, defenders of choice and veil wearers (unlike their own mothers). How to explain this apparent contradiction? According to Roy, France has it all wrong if it thinks democracy and secularism necessarily go hand in hand, at least in many parts of North Africa and the Middle East. That's because it has often been militaristic dictatorships that have sought to impose secularism by force in so many failed states in the region. It is the opponents of military strong men in places like Tunisia, Algeria and to some extent even Turkey who have taken up the veil as an assertion of their rights and can't conceive how French democracy can find it so threatening.

The health reform industry in full (academic) swing

It was upton-on-line's misfortune, in a former life, to have inherited the health portfolio. Who knows what bad kharma dictated this fate? But one aspect of the ensuing purgatory that proved more absorbing than most was exposure to the steady stream of honours and graduate students seeking interviews as input to their research essays and theses. The quality of the projects was widely variable, some being little more than exercises in applied ideology. What they revealed, however, was the veritable industry unleashed in academia by reforms to the health system. So an invitation to review three recent offerings for NZ Books (first published in their December issue) was irresistible.

The least readable was Continuity amid Chaos, Health Care Management and Delivery in New Zealand edited by Robin Gauld. It consists of 17 contributions of largely descriptive prose consuming 300 pages which offer, according to the editor, 'insights into the ways in which a range of different health-care services in New Zealand are managed and delivered, and how those involved have responded to the continual restructuring of the health system'.

'Insights'? Only if an insight is the view of an insider. The authors (all dwellers in the inner temple of health management and delivery) seem to have no clear idea of their reading audience. There is certainly nothing new their peers. It is a collation of the sort of stuff which fills all manner of dreary presentations at conferences. Talking to these busy people is always far more rewarding than the acronym ridden commonplaces that somehow spill out into their prose. For the general New Zealand public it is impenetrable. And for the overseas reader? Well the problem is that it's very local and also unreflective.

Which leads one to ask, what market the publishers thought they were reaching? Maybe there are dreary diploma courses in which unfortunate students have to be able to cite some literature in describing the health system. If so, a gap has been filled. The only other possible 'market' is future health systems archaeologists. Like a time capsule buried for future retrieval, this book captures a wealth of turn-of-the-century jargon, acronyms, diagrams and accounts of what people saw themselves doing. In fifty years it will be a splendid dig for scholars studying the history of social service delivery. It will stir no debate today.

Board games for health carers

The same cannot be said for Snakes and Ladders: The Pursuit of a Safety Culture in New Zealand Public Hospitals, by Peter Roberts. This book grew out of a master's thesis in public policy at Victoria University and explicitly sets out to influence current debate. It is an exploration of the limitations and risks attendant upon an approach to the pursuit of hospital safety based on identifying errors, imposing rule-based procedures and meeting shortcomings with the attribution of blame. In place of that the author proposes a paradigm shift that would value a pervasive awareness of safety by collecting information, not so as to apportion blame but to overcome errors, and seeking to understand the motivation of teams of professionals in a way that builds trust.

The thesis was written against the backdrop of on-going reform and restructuring of hospital management, and a number of high profile cases involving the alleged failings of practitioners notably in Northland and Gisborne (the Parry and Bottrill cases for those inclined to attach blame to individuals).

In its broad thesis, few will quarrel with the view that the huge complexity of modern hospital care and the degree of professional specialisation involved does not lend itself to mechanical or retributive management systems. As Roberts repeatedly underlines, the reporting of much information which can add value to learning from experience is in effect voluntary. (Knowing about near-misses and learning from them is vital and anonymous reporting the best way of guaranteeing that you find out about them.)

Anyone acquainted with the New Zealand health and management bureaucracy will be scarcely surprised by Roberts' sustained defensive of the professionalism of clinicians even if at times he seems to place them beyond the reach of external scrutiny. But if blame is out for health professionals it is definitely still 'in' for other groups. The blame culture is diagnosed as being rooted in 'deeply ingrained societal attitudes led from Parliament'. (Phyllida Bunkle is uniquely named in this regard). The retributive command and control paradigm is favoured, we are told, by 'politicians and many bureaucrats'. The unqualified mention of politicians seems to reflect the relative attribution of animus directed by the author towards the unenlightened whose number include the media and those members of the public who have fallen so far as to consider themselves mere consumers.

The most interesting question the book raises is why its author felt moved to elaborate his views by way of a thesis. Roberts attributes his motivation to a realisation that 'bad public policy was more dangerous to his patients than the flesh-eating bug'. This is a great line for the dust jacket, but a careful reading of the book discloses a deep irony about the vehicle Roberts has chosen to influence the debate.

Snakes and Ladders is explicitly written for the policy community (and indeed published by its nerve centre, the Institute for Policy Studies). The public may not be ready for the paradigm shift, Roberts suggests, but policy makers need to be. This is the urgent message of the closing chapters. The prizes and endorsements the book has attracted suggest that the Establishment is already converted.

Hunkering down in the academic trenches

This extraordinary faith in the power of policy may go some way to explaining Roberts' need to buttress his undoubted clinical experience with all the trappings of academic formalism. This book is an unflinching route march through heavily academic terrain. Fully two thirds of the text is a survey of the literature. Bracketed references sprout liberally throughout the text, at times completely arresting the momentum of the argument. Even the smallest observations often find their parentage somewhere in the academic prairies.

This is standard grist to the academic mill but whether it represents a sound publication strategy is another matter. Theses are the means by which academic novitiates win their spurs from scholarly superiors. They have to prove they've covered the ground. (The pressure to do so makes one wonder whether academia doesn't begrudge emerging researchers the possibility of original insights!)

And herein lies the great irony: Peter Roberts brings a wealth of practical and professional insight to his chosen subject. And it is the triumph of form over substance and standardisation over unique insight that he argues against. Yet here is a policy-tuned analysis that conforms in every respect. Even Roberts insistence that we should break with linear, reductionist ways of thinking seems belied by the neatly tabular way in which paradigms are classified and programme logics described.

Here, surely, was someone who could have written an equally compelling piece of advocacy based on practical, clinical insights (and still drawn on the fascinating survey results recorded) without feeling the need to locate that analysis within the conceptual production industry that so much academic reflection submits to. It is as if the only way Roberts feels he can communicate authoritatively is vicariously, through conceptual, research-based filters.

Readers will search largely in vain for Peter Roberts own practical wisdom as against the drafting of research insights in support of paradigmatic policy shifts. Even when the author's ideological preferences are near the surface they are quickly referenced in this case, variously, to Boston and Kelsey. Everything is academically 'earthed'.

Those with a nose for these things will enjoy the familiar board game reproduced on the front cover in which the snakes and ladders have been artfully labelled the good climb upwards through teamwork, collective mindfulness and internal morality, the bad slide down on the back of protocols, control and dreaded individualism. If this is the purgatory of public hospitals, one hates to think what snakes are lurking in private hospitals beyond Roberts' study. Does he believe they have any ladders at all?

In the end, survey data (largely collected in intensive care units) is interpreted both in the light of what Roberts regards as a failing paradigm and what it can tell us about a better one. That much is convincingly done. But for upton-on-line, a culture change is not just a question of storming the heights of policy. Neither is it a question of locating the forces of resistance in what he terms media-political mythology . Policy has ultimately to be explicable and persuasive in a democracy. Politicians and journalists have long ago been stripped of any authority. The defenestration of doctors and other professionals is a more recent affair (which probably explains Roberts passion). But it has happened none the less.

The cult of blame is part of a much wider social phenomenon that has evolved in a society in which information is much more widely held and the currency of castes, be they political, professional or religious, greatly debased. Conservatives (of all stripes) may regret this turning of the wheel, but they would be foolish to believe that any corrective will spring fully armed from the world of policy.

Border skirmishes

The same levelling forces that have rattled the gates of the professions have often embraced alternative, and sometimes completely counter-cultural, belief systems. This is the territory into which Kevin Dew steps in his Borderland Practices

Regulating Alternative Therapies in New Zealand. This book, too, started its life as a doctoral thesis but the gestation period was much longer than in Roberts' case. The result is much more readable. The ropes and pitons left behind in the academic ascent do not intrude as they do in Roberts' case. Dew's peak was not conquered yesterday and the result is altogether more discriminating and thoughtful. If publishers are considering re-jigged theses, this is the presentational standard they should be seeking.

Dew's book is about the relationship of alternative therapies to the medical mainstream in New Zealand and the people who inhabit and police this shifting 'borderland'. Along the way there is some fascinating history recounted on how orthodox medicine made its way to centre stage and has stayed there. Three particular skirmishes are recounted in some detail: the outcome of the Commission of Inquiry into Chiropractic of 1978 (a case of outsiders being brought inside the pale); the rise to acceptance of acupuncture from within the ranks of the medical profession (a case of internal deviancy being accepted); and the expulsion of Mat Tizard from the medical register for disgraceful conduct following claims he made about chemical poisoning and his ability to treat it using electro-acupuncture.

The dissection of each of these cases is fascinating. Dew exposes the deft way in which the Commission on chiropractic managed to endorse the discipline on the basis of its effectiveness in respect of a limited scope of complaints without buying into its more esoteric claims. Similarly, he highlights the way in which medical practitioners who adopted acupuncture stressed the practice rather than the philosophy. Amusingly, we learn that one doubt doctors had about chiropractic was that it had only spread in countries influenced by America! (Surprisingly, Dew does not explore the possibility that acupuncture s acceptance from within the mainstream might have something to do with western respect for an ancient and sophisticated culture that has embraced western medicine without letting go of those techniques widely regarded as effective by Chinese patients and physicians alike).

Dew's verdict on the Tizard case is likely to arouse sharp disagreement. For upton-online's part, he adduces insufficient evidence to support his verdict that it was all part and parcel of the medical profession using its power to suppress someone who threatened its hegemony. His conclusions on the causes and uses of standardisation and limits on clinical freedom are less controversial (and strike a broad resonance with Roberts' diagnosis) if somewhat bald: standardisation techniques (such as quality assurance programmes and protocols) are cost control tools driven by fiscal pressures; doctors embrace them to maintain their legitimacy.

Notwithstanding Dew's remarkable claim that there has been a global trend to cut health expenditures since the 1970s, upton-on-line's hunch would be that the bewildering proliferation of interventions and technologies has forced health administrators to say something about outcomes to justify the inexorably rising costs of health care driven by even faster rising (and frequently unrealistic) public expectations.

But unlike Roberts, Dew lets some doctors do some of the talking on these normatively charged issues rather than stay in the world of abstract paradigms. Seven doctors who have in different ways embraced alternative elements into their practices are interviewed. Their range of views is fascinating and provides the element of individual practical wisdom missing from Roberts' account. Here we find a first hand account of the struggle working doctors have reconciling the objectivism and rationalism science demands with the individuality and differentness of the patients they are trying to help.

The submerged ethical mine-field

Only in the closing pages does Dew touch and then only fleetingly on the great political conundrum that lies submerged beneath so many health debates: how to reconcile a taxpayer-funded health system with increasingly plural, and not always commensurable, views about what treatments are legitimate. The problem is far from being merely budgetary (safe ground to which, one senses, Dew would happily hew), at the base of any public or social democratic health system resides the fundamental claim that human well-being can be collectively known and stated.

And in terms of our experience of pain and suffering that seems so intuitively right. The problem is that, along with that assumption, goes the claim that we can actually secure it. And that is where the problem starts because if we are going to claim we can deliver the outcome, any democratic system of accountability must have a way of testing that. When something as individual as a sense of well-being is at stake, informed as it often is by powerfully divergent belief systems, it is idle to believe there will not be contested versions of what should and should not be provided.

It is only a short step from here to deciding that we can't determine all this bureaucratically and that if we want to respect differences and choices - without breaking the bank - some sort of market for vouchers is where the logic leads. But before anyone embraces this heresy they would have to explain what they would do faced with bad choices.

If there is one immutable law in political cultures such as ours, it is that no government can ever admit that it will stand indifferently aside in the face of suffering caused by illness. (The fact that that may be the effect of its policy choices is another matter). So the risks always end up being shouldered by taxpayer-funded services. As long as they are, outcomes will be contested and the effectiveness of expenditure will always be in the public, political arena. And there is no escaping the arc lights of popular debate in a society that feels ever more entitled to challenge claims of expertise whoever makes them.

If Kevin Dew avoids these issues, he more than does justice to his chosen terrain. This is a book that can and should - be read by a wide audience.

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