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News and resources on French thinker Michel Foucault (1926-1984)

Street, A.A , Coleman, S.B. Introduction: Real and imagined spaces, Space and Culture, Volume 15, Issue 1, February 2012, Pages 4-17

Abstract
The hospital’s ambiguous relationship to everyday social space has long been a central theme of hospital ethnography. Often, hospitals are presented either as isolated “islands” defined by biomedical regulation of space (and time) or as continuations and reflections of everyday social space that are very much a part of the “mainland.” This polarization of the debate overlooks hospitals’ paradoxical capacity to be simultaneously bounded and permeable, both sites of social control and spaces where alternative and transgressive social orders emerge and are contested. We suggest that Foucault’s concept of heterotopia usefully captures the complex relationships between order and disorder, stability and instability that define the hospital as a modernist institution of knowledge, governance, and improvement. We expand Foucault’s focus on the disciplinary, heterotopic qualities of the hospital to explore the heterotopia as a space of multiple orderings. These orderings are not only biomedical. Rather, hospitals are notable for the intensity and heterogeneity of the ongoing spatial ordering processes, both biomedical and other, that produce them. We outline an approach to heterotopias that traces the contingent configuration of hospital space through relationships between the physical environment, technologies, and persons, while simultaneously considering the kinds of spatial imaginings, hopes for the future, and emotional responses that are rendered possible by those configurations. We provide three thematic frameworks through which the heterotopic and contingent qualities of hospital spaces might be explored: boundary work, generating scale, and layered space.

Author keywords
biomedicine; heterotopia; Hospital ethnography; medical anthropology; STS

For an article in response to this article see Comments

One thought on “Real and imagined spaces (2012)

  1. John Desmond says:

    I am extremely grateful for this post because of my interest in the viability of democratically-run public sector health services.

    I will express my gratitude about the post with information about a recent initiative inaugurated by an as-yet apparently small number of police authorities in England and Wales.

    The initiative is called ‘OWL’, for ‘Online Watch Link’, and is an online development of neighbourhood watch schemes. The original neighbourhood watch schemes were based upon meetings of neighbours held in each other’s houses, each scheme being co-ordinated by a nominated individual.

    The original neighbourhood watch schemes didn’t become as widespread as was hoped because people would not make the necessary commitment of time. Consequently, someone somewhere had the idea of creating online versions of the schemes, which are based upon the creation of local email contact groups to which the local police service regularly sends emails about crime events in the locality. I enrolled in my local scheme last April. Since then, the range of the subjects of the emails which I have received has quickly and dramatically increased. The subjects of the emails which I initially received were crimes perpetrated in my locality, including their nature and locations. Soon afterwards, the subjects of the emails which I subsequently received included:
    • methods of preventing recently-perpetrated crimes, for example burglaries and thefts from public-parked cars
    • arrests about locally-perpetrated crimes
    • information about the conviction of a offender accompanied by an attachment of a leaflet which documented his name, his address and his police photograph, of which more later
    • a reward for information leading to a conviction for cable theft.

    A police support officer who visited my house told me that the local organizers of my local ‘OWL’ scheme were ‘raving about it’. I envisage such schemes linking with the practice of ‘predictive policing’, a concept from the United States which aims to reduce burglaries.

    Five characteristics of ‘OWL’ stand out for me:
    • its fulfilment of the metaphor of the Panopticon model of surveillance
    • its creation of ad hoc subcultures to counter criminal subcultures
    • its promotion of vigilance, of which more later
    • its potential to reduce crimes such as burglaries, and thefts from garages and publicly-parked cars
    • its consequent potential to progressively reduce the scope for criminals to perpetrate such crimes.

    I find ‘OWL’ personally beneficial, yet morally ambiguous and disquieting.

    On the one hand, I have benefitted from and consequently appreciate its effective promotion of vigilance, particularly front-door vigilance. This can be understood from the occurrence of two local crimes. In 2010, a young student opened the door of his home, expecting a visit from his Koran teacher. Two men wearing balaclavas rushed in, wielding daggers above their heads and started to stab the young man in the presence of his parents. Despite the valiant attempts of his parents to defend him, he later died from his injuries. Two men are currently on trial for his murder, the tragic consequence of an apparent case of mistaken identity. In April this year, two men wearing balaclavas entered a house, pushed past a female occupant and stole jewellery before leaving. The woman suffered a minor injury to her hand and was taken to the local hospital for treatment.

    On the other hand, I am unsure about what precise purpose is served by sending an email to a contact group with an attached leaflet which documents the name, the address and the police photograph of a convicted offender. Also I have reflected upon the psychological impact of such an email upon the members of the offender’s family and local community.

    Finally, I have yet to encounter an anarchist reaction to the inauguration of ‘OWL’ schemes. I await such a reaction with interest, particularly from an anarchist who is familiar with the emphasis placed upon vigilance by anarchism in the late nineteenth-century and early twentieth-century. (See Alexandre Skirda [2002: 18,19,88] in his Facing the enemy A history of anarchist organization from Proudhon to May 1968. Translated by Paul Sharkey. Edinburgh: AK Press.)

    These comments are based upon two concepts which I am currently developing: the concept of an enclave and the concept of feedback commitment. I define an enclave as as ‘a collectivity in which its centre of power ignores and cuts itself off from its external milieu’. I define feedback commitment as ‘the commitment to invite feedback’. The concept of an enclave is based upon the concept of feedback commitment, which is itself based upon the doctrine of fallibilism (see Peirce, 1955, originally 1897: 58-59, for a helpful ordinary language account of his doctrine).

    The concepts of boundedness and permeability will be linked with the issues about the accountability and ownership of the current basic organizational units of the Welsh National Health Service (NHS), its local health boards.

    Enclaves are, by definition, bounded. They exist in the third sector, as groups and organizations. (See Desmond, 2012 about organizational enclaves in the third sector.) A business is extremely unlikely to become an enclave because, if it did so, it would probably fail. A department in a public sector organization can be an enclave, of which more later.1 A public sector organization as a whole is unlikely to be an enclave because public sector organizations are usually permeable. (This writer is unsure whether boundedness and permeability apply to psychiatric hospitals because of their usual geographical remoteness.)

    Most businesses, particularly retail ones, assiduously invite feedback from their customers. They have a fundamental incentive for doing so: the prevention of financial failure. Public sector organizations do not have this incentive. Correspondingly, and in my experience, Welsh local health boards do not assiduously invite feedback from their intended beneficiaries, which significantly reduces accountability to them and partly prevents ownership by them. (I suggest that ownership can also be prevented by geographical remoteness, of which more later.)

    Initially Wales had thirty-one local NHS trusts, which were created with the aim of enabling their local communities to own them. Following two re-organizations, they have been replaced with seven NHS health boards. The geographical domains of the health boards are too large to count as local communities. Consequently they cannot be owned by local communities.

    This situation contrasts with the situation which existed during the late nineteenth and early twentieth centuries in the town of Tredegar, South Wales. The town was heavily industrialized, being based upon iron production and coal mining. Correspondingly it had serious medical problems. But fortunately it also had a medical aid society which successfully ran a health service comprising the provision of both primary care and secondary care. The ‘Tredegar Medical Aid Society’ was not the only medical aid society which existed then. Other societies existed in South Wales and similar societies existed in England. But the Society became famous because a resident of the town, Aneurin Bevan, became the Minister of Health in the post-Second World War Labour Government of the United Kingdom and used his familiarity with the Society to help create the NHS.

    Five characteristics about the ‘Tredegar Medical Aid Society’ help to explain why it was accountable to and owned by the local people. First, Tredegar is a small town. Second, it is bounded by, on three sides, mountains: it is at the head of a valley. Third, like all Welsh people, its inhabitants were naturally curious. Fourth, as a consequence of these three characteristics, ‘everyone knew everyone’. And fifth, 95% of the adult inhabitants were reputed to have belonged to the Society.2

    Despite vigorous opposition from the supporters of the medical aid societies, the officials in the Ministry of Health for which Bevan was the Minister ensured that the NHS supplanted them (see Green [1993: 91-100]). According to David Green, the officials ‘devoutly believed that the National Health Service would be a vast improvement on the status quo:

    “… the societies cannot command the whole range of services which the patient is to be offered in the new scheme. [If] these services are not all at the societies’ command, they cannot keep up with the standard elsewhere even if they are better at the start.”3’ (op. cit.: 93)

    William Beveridge, whose ‘Social Insurance and Allied Services’ report served as the basis of the welfare state, was sufficiently worried about these claims to issue a warning, published in the Letters page of ‘The Times’ of 5 February 1946, that to create an ‘all-embracing State machine will be final’. His warning went unheeded. Subsequently the finances of the NHS proved to be resistant to budgetary control. Consequently its initial all-embracingness was eventually replaced with local NHS trusts. As has been stated, the Welsh NHS has local health boards. They have trustees who are appointed remotely and anonymously by its Department of Health in Cardiff. None of the re-organizations of the NHS in Wales brought the provision of primary care into the public domain. Consequently Welsh health centres and surgeries remain as they have done since the creation of the NHS, private businesses.

    The administration of Welsh NHS local health boards, health centres and surgeries contrasts with the administration of the medical aid societies in South Wales, which Steven Thompson (2003) described as being ‘carried out within a proletarian public sphere.’ (op. cit.: 91) The contrast is suggested to repay detailed and careful study, particularly about the current received medical wisdom in Wales about concentrating specialist hospital-based medical services in fewer hospitals.

    John Desmond
    2nd October 2012

    Notes
    1. I can easily imagine a small department in a large hospital being an enclave, squirrelled away in a remote part of it. I can also imagine a manager of such a department essentially preventing it from being permeable.
    2. Another characteristic was Walter Conway, the guiding light of the Society, who served as its Secretary from 1915 until his death in 1933.
    3. Public Records Office, MH77/93.

    References
    Desmond, John. 2012. Organizational enclaves in the third sector.
    Unpublished paper available from the author.
    Green, David G. 1993. Reinventing civil society: The rediscovery of welfare
    without politics.
    London: Civitas.
    Peirce, C.S. 1955. Philosophical writings of Peirce. Edited by Justus Buchler.
    New York: Dover Publications.
    Thompson, Steven. 2003. A proletarian public sphere Working-class
    provision of medical services and care in South Wales, c. 1900-1948.
    Chapter 5 in Medicine in Wales c. 1800-2000 Public service or private
    commodity?
    Edited by Anne Borsay. Cardiff: University of Wales
    Press.

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