I’ve been thinking a lot lately about the concept of complexity. Complexity thrills and challenges me, especially social complexity. Two of my favorite scientists, Richard Lewontin and Richard Levins, persuasively argue in their (incredible, must-read) book Biology Under the Influence: Dialectical essays on ecology, agriculture, and health, that the social and the biological are inextricably linked; how we frame questions and who we ask in many ways predetermines the answers. This is the primary reason why I don’t believe that neutrality in science is possible; as Lewontin and Levins themselves state, “as a product of human activity, science reflects the conditions of its production and the viewpoints of its producers or owners” (2007, p. 90). When we’re faced with a complex problem, what questions do we ask to elicit understanding, and who do we ask? Different starting points lead us to very different conclusions.
Type 2 Diabetes is a great example. If you consult the Canadian Diabetes Association website they will define type 2 diabetes as “a disease in which your pancreas does not produce enough insulin, or your body does not properly use the insulin it makes. As a result, glucose (sugar) builds up in your blood instead of being used for energy.” In my work as a Registered Midwife, we are taught to talk to women about risk factors ranging from family history of the disease, age, and body weight to lifestyle and ethnicity. Some of these risk factors are completely ascientific – purely social categories. If a woman has abnormal post-fasting glucose levels, we send her to an endocrinologist and a diabetic counselor; we may be able to help women normalize their blood sugars, but how are we impacting the disease? After many years of witnessing predictable patterns of whom amongst my patients were diagnosed with gestational diabetes, and hundreds of hours leading popular health education workshops with the Alliance for People’s Health (APH) it became increasingly obvious to me that diabetes is a disease of colonialism and capitalism. Through the People’s Health Series at the APH I heard dozens of stories of the impacts of gross food injustice on exploited communities. Through community mapping we collectively identified almost-impossible access to land and fresh foods and ubiquitous access to cheap junk foods. The poor are often living enforced sedentary lifestyles. I changed the way I talk to women about the disease out of frustration at both the narrow biological construction and medical orientation of the disease as well as the blaming and shaming that accompany diagnosis. I now ask very different questions about diabetes and look to lay communities for the answers.
As it turns out that there are many others out there who agree with this perspective; those who seek to challenge narrowing complex social phenomena as diseases biological in origin. There are many out there who critique a narrow, Western, biomedical framework for understanding disease – not just diabetes, but other diseases, too. This is not to say there isn’t a role for medicine, but that bio-medicine should not be our starting place. Embracing the complexity of diabetes requires confronting major social and economic challenges: the generational impacts of colonial occupation and privatization of the land, forced human migration, mass death from unknown diseases, loss of traditional healing methods and forced separation from traditional plants, commodification of food, and separation from traditional and natural food sources (Davis, 2013; Waldstein, 2010). Some are even asking: how does diagnosing someone with type 2 diabetes contribute to harm? In her excellent paper Coping with diabetes and generational trauma in Salish tribal communities, Renee Davis remarks, “bio-medical rationale and methods often mimics the ideologies of government policies of early colonialism” (p. 57). Through my own midwifery work at the Strathcona Midwifery Collective and through my popular work with the Alliance for People’s Health I have learned first-hand that we can harm people with our narrow views; structural racism is embedded in Western medicine and science. This is why I was drawn to my own questions of the harms caused by Western prenatal practices within working class and historically and systemically-oppressed communities.
When tackling complex problems, social, biological, or ecological, one final question worthy of consideration: who is going to benefit from proposed solutions? Directly benefit, in economic and social terms: prestige, status, income, and material comforts – not just biomedical outcomes as in reduced disease incidence. Parting words from Lewontin and Levins, “[t]here is, then, a growing conflict between the urgent need of our species for the integration and democratization of science, and the economics and sociology of commercialized knowledge that impedes such development. We might attempt merely to predict, detect, or to tolerate the outcome of that conflict. Or we could join the struggle to affect what happens.” (p. 217).
Davis, R. (2013). Coping with diabetes and generational trauma in Salish tribal communities. Fourth World Journal, 12(1), pp. 45-78.
Lewontin, R.C., and Levins,R. (2007). Biology Under The Influence, Dialectical Essays on Ecology, Agriculture, and Health. New York: Monthly Review Press.
Waldstein, A. (2010). Popular Medicine and Self-Care in a Mexican Migrant Community: Toward an explanation of an epidemiological paradox. Medical Anthropology, 29(1), pp. 71-107.
“Philosophers have hitherto only interpreted the world in various ways; the point is to change it.”
Karl Marx, Theses on Feuerbach, 1845
“The irrationalities of a scientifically sophisticated world come not from failures of intelligence but from the persistence of capitalism, which as a by-product also aborts human intelligence.”
Richard Levins and Richard Lewontin, The Dialectical Biologist
Recently I started graduate school after several years working as a midwife in Vancouver and rural Philippines with Community-Based Health Programs. And, yup, I’m definitely a ‘red’. Prior to grad school my research experience stemmed from my pre-midwifery years as a community organizer, activist, and participatory action researcher for anti-poverty, feminist, and environmental justice organizations. During those years I had a handful of interactions with academic researchers; interactions fraught with tension over world views, priorities, and the commodification of research for professional advancement. Yet, during my work as a midwife I faced questions I wanted to explore; graduate school allowed me to carve out time to address challenges facing Registered Midwifery.
Reading Lélé and Norgaard’s “Practicing Interdisciplinarity” (2005) resonated for me as they discuss how world views, values, and theories shape supposedly value-neutral scientific research. My orientation towards social justice, human rights, and reciprocity fundamentally shape my research on the prenatal care experiences of poor and marginalized women. My love of dialectical materialism, a profoundly trans-disciplinary method of understanding complex social and ecological phenomena, helps me grasp the social, political, institutional and economic relations which shape the design and provision of medical care in modern society. The closest (not openly Marxist) ‘fit’ with dialectical materialism I have read thus far in the scientific literature comes is Nancy Krieger’s eco-social model (eg: 2012). My feminist standpoint necessarily allies me with the women I care for, am with as midwife, and challenges me to break down the false dichotomies of experience and ideas (Oakley, 1998). Our economic and social position in society shapes our perspective on the world. The concepts of research evidence as ‘proof’ and the confines of discipline have been challenging for me, and brings up the tensions I have previously had with academics, that in order to be rigorous, knowledge and ideas must be crystallized through the lens the Western academic project.
CP Snow’s seminal 1959 lecture “The Two Cultures and the Scientific Revolution” challenges the culture of Western intellectual life, or rather the ‘two cultures’ of natural sciences and the humanities, to collaborate to tackle the growing chasm of underdevelopment. CP Snow calls on the ‘two cultures’ to unite in the grand project of exporting the Western scientific revolution and its capital, scholars, scientists, systems of education, and colonial gaze to the (forcibly) underdeveloped world. He poses capitalism as the correct path forward and the neo-colonial project the goal. CP Snow was a Baron, a peer in the House of Lords, and in my opinion espoused the world views of the European bourgeoisie who had flourished precisely because of the colonial plunder of developing nations and the mass export of surplus labour to the settler states in the Americas. In his context, the shift from colonialism to neo-colonialism is strategic. But as Richard Levins states in Living the 11th Thesis, “…there was another view, that each society creates its own ways of relating to the rest of nature, its own pattern of land use, its own appropriate technology, and its own criteria of efficiency” (2008, p. 30). Not only did the wealth of the colonies bolster Western development but many technological, agricultural, and pharmacological advances originate in appropriated indigenous knowledge and practices which have sustained communities and worked in harmony with the environment for many generations.
So here I am in graduate school struggling with the confines of discipline, contradictions in the ownership and authorship of research based in community experiences, and grieving the fact that Western medicine (midwifery) can actually harm people. I believe we’re in this grand environmental and social catastrophe because of the inherently self-interested, short-term, national chauvinistic and narrow-minded nature of the capitalist system. I’m inspired by Richard Levin’s “Living the 11th Thesis” and his call, which in some ways is similar to CP Snow – to meld the social and natural sciences – but in many ways different – to meld academia with social justice. Our scientific endeavors can and must respect unique (and oft poorly understood) world views, uphold human rights and self-determination, promote reciprocal collaboration, and contribute to the betterment of humanity. My attempts to live the 11th Thesis are to enter my research with intention to make change, to shift the practice of midwifery care, and to incorporate the concept of social justice in all aspects of my work. Living the 11th thesis keeps alive the challenges that brought me to my research to begin with: the discounting of the voices of the ‘other’ in clinical work, the overemphasis on Western biomedical viewpoints, and the underlying truth that Registered Midwifery is predominantly a white, middle class, colonial project.
- Krieger, N. (2012). Methods for the Scientific Study of Discrimination and Health: An ecosocial approach. American Journal of Public Health, 102(5), pp. 936-945.
- Lélé, S. & Norgaard, R.B. (2005). Practicing Interdisciplinarity. BioScience, 55(11), pp. 967-975.
- Levins, R. (2008). Living the 11th Thesis. Monthly Review, 56(8). Available on line.
- Marx, K. (1845). Theses on Feuerbach. Available on line.
- Oakley, A. (1998). Gender, Methodology and People’s Way of Knowing: Some problems with feminism and the paradigm debate in social science. Sociology, 32(4), pp. 707-731.
- Snow, C.P. (1961). The Two Cultures and the Scientific Revolution [the Rede Lecture]. New York: Cambridge University Press.
Passion, Justice, and the “Hidden Curriculum”
Over the past couple of weeks I have had excellent discussions with midwifery colleagues on the cultural, ideological, and psychological changes student midwives experience as they navigate the “hidden curriculum” in medical education. In 1998 Hafferty defined the hidden curriculum as “a set of influences that function at the level of organizational structure and culture” (Hafferty, 1998, p. 404); Mossop et al (2013) build on Hafferty’s work, applying the concept of the cultural web to reveal core elements of the hidden curriculum, including “routines”, “rituals”, “control systems”, and “power structures” (p. 135) as important influences on the development of the professional identity, authoritative knowledge, and clinical practice.
In 2003 I began the UBC Midwifery Education Program eager to expand upon my women’s health activism and social justice work. The daily rituals and routines of obstetrics in the hospital environment moulded me into a practitioner with a high level of functioning in the tidy boxes of obstetric diagnoses and distanced me from the messy world of the social determinants of health. My rotations in Maternal Fetal Medicine and Obstetrics left me very comfortable in world of rare obstetric complications and high-level medical interventions, with a tool-box full of medical knowledge and technological skills. In keeping with the call of Paul Glasziou et al (2011), I did experience my UBC medical education as a “life course”; we were taught to be life-long medical learners, to critically appraise medical literature, to convey this vast literature to our patients, and formulate evidence-based clinical care plans. However, I chose to go to midwifery school, not to medical school! It took me 5 years post-graduation to realize that the practitioner I had become was not the practitioner I aspired to be, and that the radical traditions of midwifery I loved were not actively being reflected in my daily practice.
A Life-Long Learner: Back to the Community
My midwifery education was fraught by challenges; my world shrank as I was increasingly immersed in the hospital delivery ward, and my visions of social justice became increasingly focussed on preventing maternal morbidity and mortality. When I graduated I faced serious questions of whether or not it was even possible to use my knowledge and skills in the service of greater good, in the reclamation of woman-centered birth culture, to challenge the positivist nature of biomedical epistemology, and to open up possibilities of meaningful social transformation.
Midwifery can be considered a radical tradition with deep affinity towards a process Shultz describes as a “battle” to “include indigenous knowledges as legitimate epistemic contributions” (2013, p. 47). Advanced medical technology and practice has the potential to save many lives in the birthing room, but this same medical system continues to play an important role in the oppression of women, in colonial and neo-colonial expansion, unsustainable ‘development’, and the active suppression of different ways of knowing and cultural healing practices.
My year spent working in community-based health programs in peasant communities was a painful and wonderful challenge to my limited ‘Western’ midwifery practice. In the real world of exploited and oppressed peasant communities maternal mortality is indeed an important site of struggle, but ultimately this struggle is dwarfed by greater problems of severe hunger, land theft and landlessness, feudal exploitation, militarization, and political repression.
Midwifery, Solidarity, and Education as a Problem-Solving Process
Now I work in a small collective of midwives who support me in striving to combine midwifery activism and social justice, connecting imperatives to transform birth culture, empower systemically-marginalized families, build communities based on collaboration, and stand in solidarity with indigenous struggles. For our collective, our ongoing midwifery education is a daily practice centered in the communities we serve. As a collective we seek to break out of the confines of our professional practice and find a deeper meaning for midwifery (Uttal, 2011) through engaging our communities on how to work together to solve the major crisis facing the Western ‘culture’ of childbirth where cesarean section rates surpass 40% in some hospitals (PSBC, 2014) and maternal morbidity includes post-traumatic stress disorder from iatrogenic birth trauma and state-led child apprehensions.
I hope that the midwifery students in our practice have a refreshing experience of a different sort of ‘hidden curriculum’ grounded in human rights, liberatory epistemology, and community-based health and healing practice. While discussions on the role of the ‘hidden curriculum’ have been inspiring for me these past weeks, I’d like to deepen these conversations to include the ‘hidden histories’ of Western educational institutions and the ‘hidden structures’ that shape our world. Midwives have the potential to transform birth culture, learn from different views and cultures of birth, and stand in solidarity with indigenous communities demanding their rights and protecting our planet from imminent destruction, but only if we give it our concerted efforts.
- Glasziou, P.P., Sawicki, P.T., Prasad, K., & Montori, V.M. (2011). Not a Medical Course, but a Life Course. Academic Medicine, 86(11), p. e4.
- Hafferty, F.W. (1998). Beyond Curriculum Reform: Confronting medicine`s hidden curriculum. Academic Medicine, 73(4), pp. 402-407.
- Mossop, L. Dennick, R., Hammond, R., & Robbe, I. (2013). Analysing the Hidden Curriculum: Use of a cultural web. Medical Education, 74, pp. 134-143.
- Perinatal Services BC. (2014). Perispectives [On-line Newsletter]. January 6, 2014. Available here.
- Schultz, L. (2013). Engaged Scholarship in a Time of the Corporatization of the University and Distrust of the Public Sphere: A decolonizing response. In, Shultz, L. & Kajner, T. (Eds.), Engaged Scholarship: The politics of engagement and disengagement. Comparative and International Education (Series Title). Dordrecht, Netherlands: SensePublishers.
- Utell, J. (2011). Practical Wisdom and Professional Life. The Chronicle of Higher Education [On-Line Journal]. February 25, 2011. Available here.