Friday, 16 May 2003
GENEVA, Switzerland
Is there a better place to put a city than where a lake becomes a river? You locate the central functions where you can build a bridge across the narrow part of the river and then you build out from there. Julius Caesar visited Geneva. Now I'm here.
Geneva, Switzerland
Geneva is in the French-speaking part of Switzerland, so I try hard to conjure up the French I learned in high school. I can order in a restaurant and buy a newspaper without embarrassing myself too much, but the political posters are harder. There is an election on Sunday and the people of Geneva are voting on whether to phase out nuclear power and rent control and there are posters advocating both sides all around town. When I ask, my colleague Susan Wilburn explains the politics of each poster, but I don't really understand yet.
Susan is on sabbatical here working with the International Council of Nurses. Susan and I are both registered nurses; back in the U.S., Susan does occupational and environmental health advocacy work for the American Nurses Association. The ANA and the ICN are both member organizations of Health Care Without Harm. In HCWH, we do our work through workgroups and Susan is the co-chair of the Nurses Work Group.
This morning, Susan and I went to the opening session of the People's Health Assembly, the pre-World Health Assembly meeting of the People's Health Movement. The People's Health Movement is a three-year-old effort to provide health care for all. We heard speakers from Guatemala, India, Iran, Sri Lanka, and El Salvador talk about their efforts to provide primary health care and the political forces that are getting in the way: pharmaceutical companies that only want to make drugs for the diseases that afflict the people who have money to pay for the drugs, Coca Cola buying up water rights, corporations claiming the intellectual property rights or patents for traditional medicinal herbs or for viruses like SARS.
The People's Health Movement has produced a charter that lays out a vision of a people-centered health sector. The charter also amounts to a call to action to tackle the broad determinants of health: economics, societal arrangements, politics, the environment, war, violence, and natural disasters. You can read about the work of the PHM and sign on to the People's Health Charter at the group's website.
As I sat and listened this morning, I thought about how different the PHM is from Health Care Without Harm. We have nothing like the PHM's nine-page charter. Groups that want to join only need to sign on to our mission and goals. We are much more outcome-based, I guess: focused on winning what can be won now, hoping that what we gain from each victory will help us win something larger. HCWH seems more intuitive while PHM is more declarative.
I think the intuitive, learning-as-we-go, getting-things-done style of Health Care Without Harm is one reason that we've enjoyed the strong involvement of nurses and other women health care workers. (Here, I started writing a little apology for not equally praising the involvement of the men in Health Care Without Harm. But I'm not going to do it. They know they're good.) Twenty years ago Carol Gilligan wrote In a Different Voice, an extraordinary work about women's psychological development and the difference between male and female moral-decision making.
Gilligan writes about Piaget's studies of play, in which he found that as they grow up, boys become increasingly fascinated with the legal elaboration of rules and the development of fair procedures to resolve conflicts. Girls, however, do not share this fascination. For girls, rules are pragmatic. Rules only matter if they make the game better. As soon as they don't, girls are ready to make exceptions. This tendency towards pragmatic tolerance led Piaget to conclude that "the legal sense which is essential to moral development is far less developed in girls than in boys."
And here's Freud explaining, "Women show less sense of justice then men, that they are less ready to submit to the great exigencies of life, that they are more often influenced in their judgments by feelings of affection or hostility."
Kohlberg and Kramer describe six stages of moral judgment from childhood to adulthood. On level three, morality is seen in interpersonal terms -- helping others. Beginning at stage four, rules become more important than relationships. At the fifth and sixth, the highest stage, relationships become subordinate to universal principles.
Girl's morality (the lesser kind) is about relationships and responsibilities. Answering an abstract moral question "Is it moral for a man to steal medicine if it is necessary to save his wife?" with "It depends" is a girl answer. For Piaget and Freud, for Kohlberg and Kramer, objectivity (it doesn't depend) has the higher moral value. Male morality is about rights and rules. Making things better is for moral weaklings.
Nursing is a level-three profession. Nurses can't diagnose. But they are allowed to think that information can be put to good use, even if it doesn't add up to absolute proof. Observations matter. Emotions matter. Intuition matters. Warnings can be listened to if there's something logical and practical you can do to stop the problem before it gets any bigger.
In Health Care Without Harm, this "thinking like a girl" in nurses and in non-nurses, in women and in men, has allowed us to win many significant victories. Not so much in the industry-made, rule-laden Congress, not in the courts. But in hospitals and clinics and markets and communities around the world.
This week is the celebration of International Nurses Day. The theme this year is "Fighting AIDS Stigma, Caring For All." For all of you who haven't celebrated yet, go out and do something "pragmatically tolerant" or "influenced by feelings of affection." You, and our world, will be better for it.
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