Technocracy and Managerialism Prof. Arvind Sivaramakrishnan Department of Humanities and Social Sciences Indian Institute of Technology, Madras Wk10 topic 10 Technocracy and Managerialism Lec 3/3 Technocracy and Managerialism – Worked Examples 57:56
Well, hello again everyone. We’re continuing with our ideologies course on NPTEL for, on the NPTEL programme for 2019-20. We’re going to look at, work on, work which shows the ways in which technocracy and managerialism both have an immense impact on our lives. And we’re going to try and analyze those impacts in the light of the theories we’ve already covered.
We have two published papers to look at. One, if I’m not mistaken, both are from the Economic and Political Weekly. I’ll send you the links of course on that accompany this lecture with a PowerPoint slide. As I’ve said before, we can’t show you the text, but we can certainly send you the links; the titles are not copyright and you can, if you have the chance, you can look them up yourselves. But let’s take a look at these two papers.
One is by B. Subha Sri, a doctor and a very experienced doctor, who has written on her upbringing, the kind of training she had as a doctor and the kind of practices she saw when she started working. Secondly, the second, well, she also talks about her own attempts to change some of those. The second paper is by, as I’ve mentioned before, by Rita and Abhijit Kothari, and it’s on management training in India.
Some of that may have changed since the paper was written, which was about I think six or seven years ago. But we’ll cover these two papers, Subha Sri and the Kothari and Kothari paper in succession. The first is on technocracy and the second is on managerialism. Okay, well, the first paper is by Subha Sri, we’ll start on that now. And she writes about the way the medical profession views women's bodies.
The paper was written perhaps six or seven years ago, maybe a little bit more recently than that, and she draws on her own personal experiences as a medical student in a Government Medical College, then in her further training, and then her work with a Dalit women's organization to reflect on the way the medical profession looks at, as she says, the woman and her body. What about her background? A very traditional Tamil Brahmin family background as she says, joint family, traditional values. And she says it was the outside world that taught her and her female relatives, her cousins presumably and her brothers and sisters, and her sisters that is, that the restrictions - that women were discriminated against, she says in her household
there was no such thing. And that includes television coverage as well, that taught them how women are discriminated against in society. Of course, starting her periods the menarche, as she says, brought its own set of taboos at home. She was expected to confine herself to certain spaces, not to enter the kitchen or touch others.
It was her grandparents who were much stricter about this, her parents were, were less strict. And there were times when she rebelled. But, she had instilled in her the idea that women's bodies were, I quote, “Dirty, especially during” again, I quote “those times.” Well, anyway, at school and home, great value was placed there, she says on science, meanings of its supposed objectivity and neutrality and something it was looked up to. They, in her family, they were all expected to, in Subha Sri’s family they were all expected to, follow a career in science. They had scientists for parents, an engineer, and a mathematics teacher. And so science was the obvious place to proceed.
Well, she got a place at a Government Medical College, Government Medical College in Chennai, and very early on, in anatomy, groups of them had to dissect a cadaver. That is what doctors do, part of the training. And they had to compare the textbooks with the actual cadavers they were dissecting. But Subha Sri also talks about how, about the nature of this encounter with the human body in the form of a dead body. She says the, the human body was, I quote, “transformed into something as dead as a log.” It was not seen as some, something that was that had once been a person with life and experiences and emotions. And she cites authorities who say health problems begin as much in the community as in the body.
Well, we know that if we think even for a little bit about that. And she cites this to say this is one of the most [things, most important things health workers and their instructors have to learn. But what happened in the actual dissecting room? Well, they were given very sudden exposure to cadavers. And the impersonality of the encounter in the context did, as she says, help students cope. They sometimes gave the cadavers names, which may have been irreverent but it may have been a coping mechanism, as she recognizes.
And each body was studied separately; they studied a few in each semester, depending on the areas of the body, the upper limbs, the lower limbs, head and neck, chest and abdomen, and so on. But the sex of the cadaver did not matter until they started studying the [reap] the reproductive organs. And when they worked on a female cadaver, they were trying, they were
learning about the, the anatomy, the anatomy itself of the female external genital organs, and of course, the internal reproductive organs.
And, the diagrams in the book seemed too complex. And nobody really wanted to talk about the issue openly. And it was always called the female anatomy, but something that they did not identify with as the role, the women in the, in, in the student group in the class. Of course, handling the cadavers as you may well know had its own social setting. The person who had to handle the cadavers was a Dalit; that is still the case. Recently I at the Chennai Photo Biennale, I saw an exhibition of photographs from a dissecting room. And there too the commentary made it clear it was only Dalits who would touch the cadavers; none of the, only one of the faculty would touch the cadavers to help the students with the dissection, and it was up to the attendant to move the cadavers and turn them around and so on and so forth. This, as Subha Sri says, reinforced an idea of the body as impure, perhaps, by example rather than, rather than explicitly.
What about the physiology lessons? The physiology of sex was of course part of the curriculum, quite right too. But the sexual act was described and the processes of, of the male anatomy, were described in great detail. But none of this was connected with pleasure or with men's or women's sexuality. And Subha Sri gives, gives an [expert], an excerpt from the textbook that they were, that they were using, and this did two things, it depersonalized the physiology of the human body in respect of the sexual organs and the reproductive organs, as it did for the rest of human body. And it equated female sexuality with childbearing, that particular textbook did - she calls this patriarchal, very likely, of course, right.
So, in the book she actually quotes the, the passages from commentaries on this kind of book, and the attitudes involved were expressed most clearly in the way that we are taught about the medical examinations of a rape victim. This was part of the curriculum, but there was no discussion about how to handle such a situation sensitively. The practicalities of taking the samples to a court of law, whenever demonstrated, and the textbooks simply spelled out what the law said. Subha Sri quotes passages to show that these are, those textbooks were very misogynist. For example, she quotes Flavia Agnes, who has written about this, and Flavia Agnes says, I quote, “a medical jurist has great responsibility, but very often they will find that the only reliable evidence depends on the liberty or life of a fellow being”. That is a quotation from Cox, cited by Flavia Agnes.
On the other hand, the concern for a victim of sexual assault is singularly lacking. It is little wonder Flavia Agnes says that young doctors make unwarranted comments about the conduct and character of a rape victim based on the level of (elas) elasticity of the vagina. “The woman's chastity, morality and virginity is put in the dock”. That’s a quotation from Flavia Agnes.
The classes on rape and sexual assault were taught separately for women, men and women students. It seemed to have, it seems to have been felt by the faculty that details of sexual assault would be titillating, would inflame the men, would make both sexes uncomfortable and would cause the men to, this is a quotation from the article, “would result in the men’s misbehaving” - that’s the actual quotation, “with women”. So even the teaching modalities, the ways things were taught, as Subha Sri says, reinforced gender stereotypes, and saw sexual assault from a, as she says, a voyeuristic perspective, rather than a way that brought out the criminal nature of sexual assaults, which is exactly what they are, criminal offences.
Now, they of course had to do forensic medicine studies, and this meant witnessing postmortems done for medical-legal purposes. Again, the bodies were handled only by Dalit attendants, and the medical officer in charge would take detailed notes from it at a distance from the table. The attendants seemed to be or she says used to be perennially under the influence of alcohol, presumably to cope with the stench and the stigma of their work. That is, of course, thoroughly understandable that they were drunk at work, even if it’s unacceptable.
Well, what about (Obstet) obstetrics and gynaecology? And this department, this teaching department was filled exclusively, almost exclusively with women dealing with women and Subha Sri says she experienced magical moments of childbirth, day in and day out. But the rhetoric, the language, talked about the patients as patients. The outpatient area was (ascend), arranged like an assembly line. Presumably, she’s referring to factory assembly lines or production lines.
All women who attended as patients had to go through a set of procedures and medical history and so on, and standard indicators, blood pressure and all the others, were taken. And they were then as Subha Sri says, shunted off to the pelvic exam area, a senior gynaecologist would, would see the patients one after another. And there was no time for the patients to dress or undress. All this was watched by groups of medical students. And the (pat), the students also read out the medical history of the patient.
There was no privacy and anyone who mentioned this, well, was scolded and dismissed, sent off without, without the medical examination, without the pelvic examination. There was, I quote, “no attempt to understand the context that she came from and her concerns and to help her undergo something as traumatic as a pelvic exam.” Similar things happened in the labour room, the delivery room, and much of this was done on a cold hard metal labour cot with none of the family or friends around.
There was no process of explanation or any such thing. The duty obstetrician was usually of the assistant professor rank and would come in every four or six hours and do a, do a sort of general round, a pelvic exam was done on each patient one after the other. So what were the conclusions? The human body was just a body. The human body was impersonal, not something each of us lived and experienced, experienced - lived with, lived in, and experienced, it was also dirty. Social norms that assigned dirty jobs to Dalits were adhered to. So social norms permeated the training establishment, the entire medical college. The difference between men and women, this is again, I quote from Subha Sri, “was only to do with the anatomy and functioning of the reproductive organs.” That’s the exact quotation. Emotions, pleasure, sexuality were essentialized into mere physiological processes. The woman's body was seen as titillating and it could induce men to be aggressive.
Men in power could use this hierarchy to abuse women. The woman's body was also something to be careful about. Women accessing healthcare, as Subha Sri says, were a set of diseases, abnormalities and physiological processes. That no doubt could be said about men patients as well, but Subha Sri has quite rightly identified the particular ways in which, in which this perspective affected women.
And in addition, the physiological process of labour was seen to be pathological. Does that mean childbirth was seen as pathological, women undergoing labour become patients? And these kinds of attitudes permeated the institution; they were repeated in the textbooks, they were repeated by teachers, they figured in the teaching methods, and the ways teachers behaved, and the system functioned. It also affected the ways the students were taught to socialize with their patients, referring to them as cases, as separate body parts, and as diseases rather than living humans, taking care not to get too involved emotionally with them.
Well, Subha Sri then went on to specialist training in gynaecology in a, she says, ‘a premier academic and teaching institution in northern India’. She says this was a revelation. For the first
time she saw women being treated as human beings. And this was an enormous difference for her, a real change.
The whole process of labour was treated with respect. The women who were undergoing labour were treated with empathy. Senior teachers reinforced the importance of being respectful to patients by being role models. Simple things like covering the patient while examining her, providing adequate privacy - these were drilled in through daily practice. Now this was obviously a very different world. And after that, after her postgraduate training, Subha Sri moved to, as she says a, a premier institution, a teaching institution in Southern India as a member of faculty in obstetrics and gynaecology.
She says this was also extremely rewarding. She saw birth companions being allowed inside the labour ward. By the way this has been done for decades in other parts of the world. I can remember watching a delivery on television oh, in, in the Netherlands, I mean it was on British television I have had a rather particular programme I happened to be watching. On British television, I watched a delivery in the, in the Netherlands, and you didn’t see the delivery itself. The woman was, was covered and the husband was in, in, in the room throughout, helping and aiding and participating, and that must have been, when did I see it? Forty years ago? Well, perhaps things are changing in India too. And in the particular hospital Subha Sri was working in, or this particular institution, the emphasis placed on evidence-based care, and on promoting a positive experience by having someone else in, a member of the family perhaps, during the labour and delivery was all noted in scientific evidence. Caesareans were audited once a month at a departmental meeting, hysterectomies were also audited before the surgery, and so on. And this particular institution took great care to visit its peripheral (hosp) visit peripheral hospitals, rural and other units to which they were attached in other parts of the state. And this gave students a sense of the infrastructure and resources in village settings, district settings, and helped to, helped them to understand the realities of women's lives in these areas.
The point is that senior faculty in this institution as well, emphasized the, the importance and value of treating (pa) women patients as women, as people, presumably by implication men patients as well, by implication. Well, Subha Sri here is talking about the way the medical profession sees women or saw women during her training. She then goes on to talk about bodies as seen by the medical profession, as against bodies as seen by women.
She moved to a community health project, a health project in Maharashtra and discovered an enormous gulf she, she says, an acute dissonance between how women viewed their bodies and how the medical profession viewed their bodies. The health worker training, which was part of a national programme, the curriculum was set, was set nationally, contained a lot of medical information to be imparted to women. And among the significant elements was women's reproductive health, of course.
Now, this involved a session where women were given the privacy to explore themselves using a mirror. Now, Subha Sri says that during this session on exploration, some women outright refused to look at their own genital organs. Some others used the opportunity to explore their, their body. Some were surprised other, others were relieved to discover that they indeed had a clitoris. Some felt a sense of shame looking at their private parts. We shouldn’t be surprised at this multiplicity of reactions. The point is, what is the doctor to learn from this or the medical student to learn from this? Well, one thing Subha Sri noticed, Subha Sri noticed was that for a lot of women there was a real, a deep sense of shame about the body parts. And as we know, the names of women's private body parts is often, the names are often used as obscenities and curse words. Subha Sri says that.
And of course they, she continued with the training. And this, this also brought out, this gave the women (presumably) the confidence to start speaking about their experience of sexual abuse, in this case from the village school teacher. And, of course that had never been spoken about in, in the school. Many of them had been at the same school, and of course, they’d never spoken about it openly. But the training session encouraged them to do that.
They also started to talk about the taboos they faced during menstruation and beliefs about how anything they touched during this period would, I quote, “go bad”, and some said how they had rebelled, so in their families and in other contexts, and saw for herself that food she touched during a period didn’t go bad and so on. So this even occurred when she went to a temple. Apparently, she had been led to believe that she would go blind if, if the God in the temple wanted her to because she didn’t have any children when she started her periods; she went into the temple walked out again, nothing happened to her, and she later had a child.
Well, the point here is the attitudes of, of the medical staff concerned and the attitudes with which they were which, which they, which they were taught during their training. Subha Sri points out, as she moves towards her conclusion, that there was a good deal of physical abuse
in a number of institutions of women during labour. This is an example drawn from, from Latin America, such as slapping women on the insides of the thighs during labour, pinching the labia or the perineum with surgical instruments, cutting the perineum and suturing without adequate anaesthesia - this is all reported by women frequently in the studies that Subha Sri cites.
Now this, let’s start looking at the wider issues here. First of all, what were the technical justifications for the practices Subha Sri has reported? Doctors have to learn about bodies - why separate men and women students when we’re training them about, about women's bodies, about men's bodies, what’s the possible technical justification for that? What possible technical justification could [there] be for the ways women were treated in the training institution that Subha Sri attended, right, in the first one she attended?
What possible technical justification could [there] be for the high-handed arrogant productionline behavior and the production-line type system in the, in the maternity wards and maternity rooms? What justification, what technical or scientific justification could be, could there be, for the kind of treatment that has been reported from, for example, for example, Latin America? Or for advising hysterectomies when as Subha Sri herself says, there was no justifiable reason?
The point here is that the technical expert, the doctor, and no doubt, not just one doctor, but sections of the profession, have as Subha Sri says, she says, the medical and allied professions, I quote, “have imbibed mainstream notions of women's sexuality as something that needs control. In a hierarchical power relationship between the healthcare provider and the woman accessing care, such power is exerted through denigration of her sexuality.”
Subha Sri goes on here: “The reduction of women into bodies and further into reproductive organs paves the way for needless procedures like hysterectomies, chop off,” I quote from her she quotes from another source, “chop off something that is useless or has served its purpose and also helps commercial interests within the medical profession.” We saw this with the, the issue on technocracy in the licensing of drugs, the British paper published by Abraham and Sheppard following a field survey.
Well, Subha Sri then says that, she then goes on to talk about the ways the medical profession views human bodies, and specifically women's bodies, and she wants to highlight three of these views. The body is an essentialized and reduced to anatomy and physiological processes, the more so in the case of women where their bodies are seen as equal to those of men, with the only difference being in the reproductive organs. This reductionist view contributes to the
impersonality of professionals and the way they treat patients seeking care - the vocabulary of cases, names of organs and so on to refer to individual patients reinforces this impersonality.
In an extreme form, it can lead to insensitivity and violence towards women in labour, and [all] women patients. It can also give sanction to unethical practices like unnecessary caesareans and hysterectomies. Now Subha Sri notes that this reductionist view of the human body is the dominant paradigm. But as she’s shown it is modified by existing patriarchal norms where that is necessary or those norms are necessary and convenient. The view of the body as dirty means that any job dealing with cadavers gets assigned to Dalits, women's bodies are seen as titillating or inflammatory, and women's sexuality is viewed solely from the point of childbirth. Subha Sri is very strong here, very firm, the medical profession, I quote, the medical profession - also quotes [to], “contributes to perpetuating patriarchal values in society by its practiced behavior, and its treatment of women and patients”.
Well, Subha Sri says her own experience of teaching women in rural areas in Maharashtra and Tamil Nadu revealed to her that women could see that the knowledge of the body was, could be, empowering and liberating. But - she says the way the same kind of knowledge was imparted in medical college was extremely oppressive and disempowering.
Their education, their medical education was totally bereft, that is her own term, of the politics of health - true of health generally, but more so with women's health where gender as a determinant of health went totally unacknowledged. Subha Sri says a great dissonance exists between the way that, the way medical training, professional training in medicine and the established behaviour of the qualified professionals, this greatly needs to be, well, an enormous gulf exists between the profession through its training and its behavior, the way it views women and their bodies, and the way women themselves view their bodies.
As she says, especially, investments need to be made in education, training of medical students to change this view. She concludes quite politely: this view affects women's lives in adverse ways. That’s putting it very politely indeed. There could be much - much - stronger descriptions of the nature and training and of doctors, Subha Sri says, particularly in relation to women, yes, this would be true of the way the men are treated as well. The significance of training and medical attitudes for women is what Subha Sri has brought out [what], Subha Sri has brought out here, and she’s very forceful about it. The thoughtful reflective conclusion that medical
education and training need to be changed is put very politely, she could have put it very much more strongly. Left to myself, I’m sure if I had the chance, I would certainly do so.
But she has made the point in a very forceful, Subha Sri has made the point in a very forceful and clear paper, drawing on her own experience in different kinds of institutions, and her attempts to change attitudes and practice in her own work.
So that concludes our examination of technocracy. The, the point for us, the real point for us is to identify not only the conduct and training and the practices concerned, but to identify the ways in which moral, political, social attitudes permeated the training. Well, we shouldn’t be surprised about that. The question then is, in what ways can particular practices and attitudes and comments and particular ways patients are treated, in what ways could, could they possibly be, could many of them possibly be justified by the claim to technical knowledge? I’m a doctor so I’m going to treat you like this. Well, what is it about being a doctor that justifies a doctor in treating patients in the ways that Subha Sri has described? Now that is really significant, right? I’ve mentioned, I may have mentioned the Black Report earlier, published in 1983. Well, the Black Committee reported or Professor Sir Douglas Black reported in 1980 if I’m not mistaken. In 1979, a conservative government had, the Conservative Party had won a majority in the British Parliament. Senior figures in the Conservative Party and no doubt, other, wider, wider sections of the membership seemed to have been convinced that poorer patients were using the British National Health Service to an excessive degree. Professor Douglas Black, FRS, was appointed to investigate.
His conclusions were so embarrassing to the government that the report was embargoed for publication, I think for about 14 months, and may have been timed for release after the, after the United Kingdom had won the Falklands War - when the government confidently and rightly expected to be reelected with a big majority, which it was.
The Black Report is freely available on the net. Professor Sir Douglas (back) Black found that patients who were clearly educated and from the upper classes got ultimately more and better treatment from National Health Service staff - treatment to which every patient was entitled - than patients from poorer classes. And they got explanations, they got more polite treatment, they got, ultimately, better medical care.
This was an enormous shock to the medical profession and all involved in NHS care and training. Nursing staff, radiographers, you name it, and very quickly, changes were introduced
and I saw this myself when I went to see my GP the next time. I did not sit across the desk from the GP; we sat at 45 degrees each to the desk with, and it was the early days of computer screens, with a computer screen in front of us.
Since then, other legislation has made our medical records much more accessible and so on. But - it was clear that, very quickly, the Black Report had made a difference, a significant difference to training. The discovery of this class hierarchy in the treatment of patients was, of course, first of all, it, it showed that this was unconsciously done. The staff themselves didn’t know it. But it was a great shock and it brought about significant changes.
So this has happened in other parts of the world. Right, this has happened elsewhere. It may well have happened since Subha Sri published her article, and no doubt the students, people like Subha Sri train will, I am sure work very differently than the, the people who taught Subha Sri and with whom she started working with in her younger days. Right, we shall, the point for us to note is - the technocrat no doubt has their expertise, we wouldn’t doubt that when we went to see a doctor. But, we need to be able to see in what ways their conduct towards us can be justified by their technical expertise.
In other words, at what point are they importing their own moral, social and other presuppositions? And could they justify those presuppositions on technical grounds? That is the point about technocracy. One implication - I’ve written about this elsewhere - is that unless we take some kind of interest both in the moral and political and social presuppositions and in the technicalities, we’re going to be at the mercy of the technocrats and their imported attitudes, the social, moral and political attitudes that permeate their own thinking.
We shouldn’t be surprised by those. The point is, how are we going to engage with them? And that is the question that a study of technocracy should lead us to conclude with.
Right. We can now go on to our second topic here. That is managerialism, our second worked example, this is a paper by well, alphabetically, Abhijit and Rita Kothari published in, again in the Economic and Political Weekly, this was in 2011 on management training in India
And the authors, Kothari and Kothari, start with an example, an example of the Diamond House, a colonial building in a quiet lane in Bombay, it was then Bombay, Mumbai, and the role this house has played foundationally in shaping the diamond trade in India. But, this was a story of a traditional trade. The owner Surajmal Lallubhai, took young men in from Palanpur and at his
suggestion they would come and live with the family and be trained in the diamond and jewelry trade. Surajmal Lallubhai was one of the pioneers of the diamond trade in India, a Palanpuri Jain, and he became a very- very - substantial figure in the diamond trade. And he would t
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