Thursday, 1 January 2015

Fiction-Non-Fiction (revisited)

In November 2013 I gave a presentation called Fiction-Non-Fiction at the 5th International Artsof Good Health and Wellbeing International Conference in Sydney. In July 2014 I revisited the same train of thought for a conference aimed at Public Health colleagues at Loughborough University organised by Creative Health. At this Collaborating in Quality Arts in Public Health for the Future event, I had in the back of my mind some ideas, not only about quality – but authenticity – in arts/health. In part, this was as a response to many of the pompous and grandiose claims made by some in the field who seem more like marketeers hitching a ride on the well-being bandwagon and seeing arts/health as a useful vehicle to sell their philosophies. It was equally a clarion call to those of us who are deeply embedded in this work, not to be suckered into a reductivist mindset, and perhaps take note of Mike White’s many illuminating blog-postings, which to me, offer the epitome of authenticity and offer polar opposites to the quick-fix pseudo-scientists. Having had a number of requests for Fiction-Non-Fiction as an essay, I offer it up here in all its grizzly glory, warts and all. So make what you will of it, typos, grammatical errors and my use of other people’s brilliance!

When Charles-Edward Winslow defined public health in 1920, he referred to the science and art of preventing disease; of education; of social machinery and realising birth rights: all things that require knowledge, political advocacy and imagination. I’d like to develop some of those ideas and think about this arts and public health agenda in terms of Winslow’s definition.

In 1966 an album called Symposium in Blues, produced by the pharmaceutical giant Merk, was distributed to tens of thousands of general practitioners in the USA, marketing their new anti-depressant, Elavil. That an album of predominantly black musicians was being used to sell an anti-depressant was a cynical piece of marketing, considering that African Americans accounted for high numbers of patients detained in mental health units and prisons across the US. At that same time, the largest epidemiological study of mental illness ever conducted in the United States, the National Institute of Mental Health’s Epidemiologic Catchment Area (ECA) Study, evidenced striking racial differences in anxiety disorders.

With inequalities in mind and much of our lives mediated by marketing, I want to think about evidence in arts/health, and ask, just what is the evidence we are after, who is it for, and who controls it?

Austin Bradford Hill was the statistician on the Medical Research Council’s, Streptomycin in Tuberculosis Trials in 1948 and their study, is generally accepted as the first randomised clinical trial. GP Ben Goldacre in his book Bad Pharma, mischievously reminds us however, that the first recorded control trial was in fact reported in the apocalyptic Book of Daniel.

Daniel rejects the royal feasts of invading King Nebuchadnezzar, preferring to eat with the servants, suggesting that they are given nothing but vegetables and water for 10 days, after which they looked healthier and better nourished than those who ate the royal food. Of course the fine food and wine is taken away, and the nobility are given the Old Testament version of five-a-day. For a religious parable, this is a million miles away from parting seas and miracle cures.

I’d argue that what we consider to be authentic and true is so deeply influenced by the pull of science and religion that it often blinds us to the truth in the name of a higher power - that higher power might be supernatural, it might be scientific - and in both cases, it is sophisticatedly marketed, making it near impossible for us to separate fiction from non-fiction.

As early as 500 B.C., Pythagoras was accepting or rejecting his students based on how gifted they looked. Aristotle wrote that large-headed people were mean, those with small faces were steadfast, broad faces reflected stupidity, and round faces signalled courage. This very classical notion of Physiognomy and assessing character and morality from outer appearance would now be described as a pseudoscience, but for centuries, as scientists searched for tangible, external clues to internal temperaments, appearance has been studied ‘robustly’.

Whilst the term physiognomy no longer resonates, physical appearance as moral indicator lives on, though our consumer-driven world has increasingly substituted clothing and material possessions as signifiers of character and we continue to label people. Your skin colour, or trappings of faith, can still get you stopped on the street for looking suspicious.

Physiognomy is a pseudo-science and is ugly and often racist, but perhaps we can understand its roots - the urge to classify and make sense of the world. In its time and place, it seemed to be the cutting edge of thinking.

2013 saw the fifth edition of the Diagnosticand Statistical Manual of Mental Disorders (DSM) published. This informs the way psychiatrists prescribe drugs and classifies those rich differences in our interior landscape.

Excessive eating will become 'binge eating disorder'
If you are too keen on checking emails, perhaps you have maybe suffering from 'internet addiction'
Is your house to messy? You may have ‘Hoarding Disorder’

Whilst being gay is still seen as a moral sin in some parts of the world, punishable by execution, at least psychiatry has loosened its grip on classifying homosexuality as a mental disorder, treatable by medication and aversion therapy.

Former chair of the DSM task force, Dr. Allen Frances, has said that he believes in the power of psychiatric treatment, but he’s concerned that: “Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form,”

And through this classification of our interior landscape, we are inevitably open to new and increasingly sophisticated technology, and nowhere is this more prevalent than the burgeoning field of neuroscience and the exploration of the human psyche.

There are 85bn neurons in the average 3lb human brain. Typically, each neuron forms 10,000 connections, through synapses with other nerve cells. Jeff Lichtman's laboratory at Harvard University has an automatedtape-collecting lathe ultramicrotome (Atlum) which over 6 days, transforms a 1mm thick slice of brain into around 30,000 slices. He estimates there are between 100tn and 1,000tn connections between neurons. Lichtman has calculated how long it might take to image every slice of a 1cm mouse brain. The answer is 7,000 years! This is big data indeed.

Our current obsession with neurology might be tempered by lessons on authenticity from earlier experiments. Following Lenin’s death, his brain was dissected into 31,000 pieces, with researchers concluding that it showed an ‘extraordinary degree of organisation,’ when compared to an ‘ordinary brain’.        

Phil Hanlon et al in Perspectives in Public Health argues that, “faith in science has morphed into an ideology best called ‘scientism’. Under scientism, what really matters is that which can be supported by evidence, can be counted or measured and, above all, can be shown to be value for money. Concerns about evidence and value for money are important, but can cause problems when taken too far,” particularly, he notes, “if metrics are used as the sole measure of success.”

What a powerful tool this big data would be in the hands of people with vested commercial interests, or even worse those who have the desire to manipulate who we are.

This arts and health movement that we are part of is growing exponentially and as a consequence, it attracts not only those of us actively involved in the field, but free-marketers’ with their eye on either a quick-buck, or perhaps a standardised tool-kit where all the nuance and complexity of culture and the arts can be packaged into a small, instrumental, do-it-yourself kit. A one size-fits-all panacea that can be branded and sold on.

It’s frequently asserted, that the only way we can prove our efficacy is through robust Randomised Controlled Trials (RCT) more often than not, holding up the pharmaceutical model as gold standard. I want to think about this conflation for a moment. Thanks to the forensic work of the GP Ben Goldacre, I’ll share some of the reasons why I feel a little unrest at the assertion that the arts/health movement somehow adopts the clinical objectivity of the pharmaceutical industry.

In 2013 GlaxoSmithKline (GSK) were found guilty of promoting two drugs for unapproved uses and failing to report safety data to the Food and Drug Administration (FDA) and fined $3bn - the largest healthcare fraud settlement in US history.  Amongst other things, GSK has admitted to promoting antidepressants for unapproved uses, including treatment of children and adolescents, until a ban in 2003, over concerns it triggered suicides.

A bribery investigation is underway in China, alleging that GSK, has orchestrated payments - said to total £321million - offering amongst other things, prostitutes to doctors to persuade them to prescribe its medicines, allegedly pushing up the prices Chinese patients pay for GSK drugs by as much as 30%.

Goldacre asserts that the pharmaceutical industry spends around twice as much on marketing and promotion as it does on research and development, much of it paid to high-esteem academic ghostwriters for pharmaceutical driven scientific journals. He suggests that this kind of fraud and deception isn’t limited to GSK - far from it, it is endemic across the pharmaceutical industry, with “66% of fraud cases in the US involving the pharmaceutical industry.”

At the moment, in the UK, even the National Institute for Health and Care Excellence who make judgements based on evidence, have no access, and no legal right to any withheld clinical data.

Thomas Carlyle described economics as the dismal science, and a narrow focus solely on the arts saving the health sector money, neglects a nuanced understanding of cultural value across society. Health and wellbeing are best promoted and protected in the very communities we live and breathe in, not necessarily the places we go to when we’re sick. And there is a danger inherent in our field of work, through the conflation of art and public good, we run the risk of reducing creativity to an economic unit - a crude commodity -nothing more.

For a twisted understanding of the fiscal value of the arts, we could perhaps look to the spiralling prison population in the US, where the government have developed a simple algorithm to calculate how many new prison cells are they going to need in 15 years time - find out what percentage of children aged 10 - 11 can read today. In fact, female literacy is a significant determinant of health, and Secretary-General of the UN, Ban Ki-moon has stressed the transformative effect on both a family and the wider community when a woman is literate. He comments, “By acquiring literacy, women become more economically self-reliant and more actively engaged in their country’s social, political and cultural life. All evidence shows that investment in literacy for women yields high development dividends.”

Albert Einstein, when asked how we could make our children more intelligent replied, "If you want your children to be intelligent, read them fairy tales. If you want them to be more intelligent, read them more fairy tales." He understood the value of both reading, and the imagination. Author Neil Gaiman reminds us, “It is easy to pretend that nobody can change anything, that we are in a world in which society is huge and the individual is less than nothing, but the truth is, individuals change their world over and over, individuals make the future, and they do it by imagining that things can be different.”

And boy, do we need to change the system. The UK has witnessed the exposure of abuse in health and social care, evidenced most harrowingly in systemic neglect within the NHS.

The Francis Report identified a target obsessed culture, that   “focused on doing the system’s business - and not that of the patients,’ {…} ‘an institutional culture which ascribed more weight to {…} methods of measuring compliance (and) which did not focus on the effect of a service on patients”.
It seems that our obsession with targets within health and social care, has blinded us to the very people we should be caring for and the all-prevailing ‘management culture’ that dominates this sector is mirrored in the arts and cultural sector too.

The Artist David Pledger, in his recent paper for Currency House - Re-evaluating the artist in the new world order, provides us with a compelling critique of the systems that have seen more money put into marketing and management that into artists, with the artist being at the very bottom of the food chain.

Yet shouldn’t the artist be at the heart of public debate? Scrutinizing, curious and enabling - questioning dominant ideologies and giving voice to those most marginalised by those in power? Pledger astutely suggests that ‘managerialism sees itself as the antidote to chaos, irrationality, disorder, and incompleteness,’ - but aren’t these the essential elements that are central to the arts?

The research of Gary Andsell of Nordoff Robbins, shares the intimacy of what Goethe described as gentle empiricism, stressing that ‘our research should always strive to “save the phenomenon”, never reducing, or replacing it with an explanation that omits human experience and its involvement in any understanding.’

Evaluation potentially confers power to justify big decisions, and RayPawson, Professor of Social Research Methodology at the University of Leeds, playfully suggests that, “mainstream science does not use RCTs. What proper scientists do is marshal theories and come up with all manner of ingenious empirical tests of those theories, which go on to refine the original ideas. Other groups add further tests to develop the explanation.”

I like this and I like Pawson’s assertion that “interventions are not ‘treatments’. Interventions are complex process introduced into complex environments attempting to deal with complex problems. It is impossible to control for every contingency as the trialists urge”. 
We are constantly told what constitutes robust evidence and more often than not, the model the RCT is held up as the Gold Standard. I don’t doubt its place at all in science and medicine, but I have grave concerns for our understanding of RCT’s when conflated with profit-driven and dishonest industry.

Perhaps the richest example of distorted evidence held up as unequivocal fact, is the UK Governments briefing report to Tony Blair in 2003. Now known as the Dodgy Dossier, we know, that much of the intelligence material was plagiarised from the graduate student, Ibrahim al-Marashi, only plagiarised with dangerous amendments designed to justify war.

From physiognomy to big pharma and political spin - what constitutes evidence, has never felt more contested. In terms of GDP, Philosopher, Vandana Shiva reflects that “a living forest does not contribute to growth, but when trees are cut down and sold as timber, we have growth. Healthy societies and communities do not contribute to growth, but disease creates growth through the sale of patented medicines”. This is a distorted understanding of progress.

She warns us that “the privatisation of health and education generates growth through profits, but it also generates poverty by forcing people to spend large amounts of money on what was previously available at affordable costs, as a common good. When every aspect of life is commercialised and commoditised,” she suggests, “living becomes more costly, and people become poorer”.

The challenge for us now, is to confidently theorise - to explore where we believe the potency of the arts lies - but in the current financial climate, do we want to be part of what Vandana Shiva describes as anti-life economics? In the face of unethical offers from bad-sponsors, can we assert ourselves with integrity? I’m thinking here of GSK’s annual ‘Impact Awards”, cynically marketed to an impoverished arts/health sector.                                

Whilst imaging our brains might offer up tantalising glimpses of how the essence of human can be nurtured, enhanced and manipulated - the true complexity of what we are, and how we engage with each other and our environment - is far more nuanced.

If we galvanise our imaginations, and envisaged our work beyond the confines of the neatly categorised sick individual, we could truly be a powerful force for social change and justice. And there’s something of a punk sensibility to the arts, from Pussy-Riot performing in Moscow, to the 2013 12th Youth Performing Arts Festival in Lahor, that despite being bombed in 2008, continues to encourage girls to take part in contemporary theatre.

Tim Lang and Geof Rayner in their article on Ecological Public Health in the British Medical Journal, ask how can we “reframe thinking about mental health, social exclusion, and inequalities in health”, without placing democracy at the heart of our thinking, where people have “a sense of - and actual engagement in shaping society and life, particularly when, we live in a “world in which so many people are excluded from control.” 

Isaac Newton in his book, The Principia wrote what is still considered to be one of the most important scientific books ever written. And not just because it set out revolutionary hypotheses about physical laws, but because it set the ‘gold standard’ in scientific writing. Interestingly, the post war economist and first chair of Arts Council England, John Maynard Keynes, described Newton, as ‘Not the first of the age of Reason. He was the last of the magicians’. I do like this economist’s reflection on the revolutionary magic of Newton’s scientific imagination.

I’d like to conclude my presentation, not with answers to questions around the value of our work, but with some points to consider:

1: SCIENTISM: NancyCartwright for the LSE suggests that “...there is no gold standard; no universally best method. Gold methods however, are whatever methods will provide the information you need, reliably, from what you can do, and from what you can know on the occasion.”

2: ECONOMICS: Hasan Bakhshi notes in his essay Beauty: valuebeyond measure? even- “...the Treasury’s Green Book guidelines for cost-benefit analysis...recommends that a range of techniques be used to elicit non-market values, even if these are subjective. Methods like Social Return On Investment may offer compelling economic proxies.

3: CULTURAL VALUE: Dr Samuel Ladkin: in Against Value in the Arts - suggests, “It is often the staunchest defenders of art who do it the most harm, by suppressing or mollifying its dissenting voice, by neutralizing its painful truths, and by instrumentalising its potentiality, so that rather than expanding the autonomy of thought and feeling of the artist and the audience, it makes art self-satisfied…”

I began with Charles-Edward Winslow’s assertion that public health is dependent on KNOWLEDGE, POLITICAL ADVOCACY and critically, IMAGINATION.

To Winslow’s definition, I would like to add AUTHENTICITY. I think we have some fundamental questions to explore, and central to this is why we do, what we do, and believe in what we believe? In our unequal and market-driven world, can we learn from the past to influence our futures - and is there a danger that if we understand impacts of the arts in terms of deficit and disease and not assets and potential, we may just become another pseudo-science? The arts have the power to change mindsets and challenge outrageous inequalities - and just how we evidence this reach, might best be understood through the very practice itself.

1 comment:

  1. Brilliant Clive. I think there could be mutualism between the science and the stories and between quantitative and qualitative researchers. But we shouldn't be made to undertake clinical trials unless we are directly asserting that that our intention is to make a clinical difference, in which case, practitioners are accountable within a clinical framework. At the end of the day. commissioning and context will determine the type of evidence required - there shouldn't be a one size fits all expectation. Brilliant, thought provoking stuff Clive!