He said it was all down to the bench outside.
Whenever there was a tricky moment in the community center, he, as one of its leaders, would take colleagues across the street, often with cups of tea in hand, and work through the issues. There was something about being out of the building, being separated from their formal roles, that made it possible for them to work through even the most challenging of issues.
There was no magic to the bench. It wasn’t more comfortable than other benches. The surroundings weren’t particularly picturesque. And yet, the process of walking out there, perhaps commenting on the litter in the street or the state of the neighboring houses, made it possible for him to find new ways to care for the community he serves.
That’s a true story, and it came to mind last week as I spoke with Andrew Binet, a PhD student in the Department of Urban Studies and Planning at MIT. Andrew calls the above process part of the ‘infrastructure of care’. The idea came to him while watching social service organizations in Toronto, Canada, respond to a massive regeneration program in Regent Park, the country’s oldest and largest public housing estate.
“I set out to study how [social service] organizations weathered the rapid and drastic changes in the social, economic and built environment of the community”, he says. What he found was that the organizations scrambled, fought, and built.
They scrambled to stabilize residents as their lives were disrupted. They fought for space for the community to grieve about lost homes and maintain community ties. And they built political capacity and economic opportunity for residents.
“I spent a long time confused about what to call what I was witnessing”, he admits. But then the penny dropped. This process, this scrambling, fighting and building, was, in fact, ‘care’ – the term is as applicable to how the organizations act as it is to the outcomes of their actions. And he saw that their actions effectively mediated between the developers and the residents.
The role of the social service organizations wasn’t planned for. They simply stepped in, despite often being under-resourced and over-worked, because they knew it’d be important for residents’ health and well-being. Andrew, as a planner, sees this ‘stepping in’ as the flow and distribution of an essential resource – care. He describes this view as an infrastructural approach.
“We typically think of infrastructure as physical networks facilitating the flow and distribution of goods, such as water or electricity, or people through space, such as roads. If we understand care to be an essential resource for health and wellbeing, then there is arguably much to gain from taking an infrastructural perspective on the networks that care is dependent on.”
As Andrew knows, he’s not the first to explore the networks that care is dependent on. In 1988, the radical general practitioner (primary care physician), Julian Tudor Hart argued that, although communities were fraying, they still existed and health care needed to remember that it is only an “adjunct” to the “self-organised mutual aid” that arises through social cohesion.
But Dr Hart, a pioneer in tackling the social causes of sickness, warned against “sentimentalizing” the role of community. In his view, the aforementioned social cohesion in industrial communities was the result of “a necessary unity” required in the “struggle with ruthless employers”. Many of those employers have disappeared as high-income countries have de-industrialized, not only taking with them jobs but also an important catalyst for social cohesion.
He also encouraged us to truly understand how ‘care’ was possible – as he describes it, through “the army of unmarried women who previously gave lifetimes of underpaid or completely unpaid service to aged parents, the chronic sick and the surplus children of their married brothers and sisters”. This army no longer exists, partly because families are smaller and more women have entered the workforce.
Dr Hart’s book chapter is not an easy read. Committed to social justice and inspired by Karl Marx, he argued that because “effective clinical medicine is not possible without a community dimension” primary care should be overseen by the local community. He went as far as postulating that this “participative democracy” approach might even help to prevent the “de-civilization of society”.
You’ll have to read the chapter to better understand why he says that. Some of you may balk at the idea of reading something under the banner of the Socialist Health Association. I have to admit that it made me uncomfortable. And yet, I also have to admit that as a winner in the inequitable status quo of health, it is only right that I’m uncomfortable now and then.
In August, I published my own contribution to creating discomfort – an updated version of our tool to apply the 12 Principles to your community health work (you can read the introduction here and download the full tool from here). I gleaned the principles from over 100 community-oriented practitioners and what they point to is the profound imbalance that exists between the health sector and communities.
Socialism. Imbalance. Scrambling, fighting, building. This week’s newsletter is not an easy read. And yet, getting to the solutions may not be as hard as it seems. If you’re in a community health meeting this week, ask yourself if you really understand the infrastructure of care in the community that you’re an adjunct to – and whether a bench might help.
- My conversation with Andrew Binet is called The Unseen Infrastructures of Care; I really enjoyed learning some of the political theories that underpin Andrew’s work
- Julian Tudor Hart’s book chapter is called The Necessity Of Community; it’s not an easy read but it contains lots of important ideas
- Dr Hart died last year and you can read an obituary in The Lancet, the journal in which he first used the now-famous term, ‘the inverse care law’
- The new version of the tool is called A Practice-Based Framework For Working With Communities
- The power of the word ‘socialism’ is being used to good [sic] effect in the US to keep drug prices unnaturally high and preserve health only for the rich
- And the bench is outside this place
Previous issues of Community & Health
- Exploring the Nuance Under the Buzz: How looking underneath buzz terms like ‘deaths of despair’ and ‘asset-based community development’ is key to finding solutions
- On Power, Co-Production and Feeling Overwhelmed: How co-production, self-management and health promotion all have the potential to increase social inequity, and what you can do about it
- Why Provision is not Enough: How atomising problems and providing programmes ignores what really matters in enabling people to turn their lives around
- Sectors, Partnering and Place: How cross-sector partnering demands thinking about place, and why thinking about place means thinking about people’s choices and freedom
- On Absurdity, Collusion and Silence: How our failure to effectively respond to non-communicable diseases may be because our science needs updating – if only our politics would get out of the way
- The Politics of Measurement: How eliciting social definitions of value may make emerging partnerships between health care and CBOs more effective
- The Social Determinants of Relationships: How other sectors are learning that the key to responding to social circumstances is deeper relationships with the citizens they serve
- The Fallacy of Behaviour Change: How a flawed idea got traction and what you can do to fight back
- When Trust Is Not Enough: A conversation with Graham Duncan about building confidence and hope amongst marginalised populations – and the psychological processes underpinning it
- The ‘Power Elephant’ in the Room: A conversation with Lauren Weinstein about how power differences are intrinsically present in co-production and what she’s doing to overcome them
- Halfway Between a Stranger and a Friend: A conversation with Maff Potts on how 20 years working at the sharp end of society has taught it him that only two things matter, and what he’s doing about it
- Lessons from the Frontline of Cross-Sector Partnering: A conversation with David Relph, formerly of Bristol Health Partners, on why collaboration has to be the core purpose of institutions concerned with health
- The Need for Human Learning Systems: A conversation with Toby Lowe on his journey from baffled Chief Executive to a key figure in the movement to find more effective ways to work in complex social environments
- The Challenge of Going Beyond the Usual Metrics: A conversation with Andrew Harrison of Revaluation and The Learning Studio on the promise and complexity of surfacing new types of value
- Effective Housing Goes Beyond a Home: A conversation with Paul Taylor, Innovation Coach at Bromford, a housing association in the UK, on why building homes is not enough
The photo behind the title is by Eric X on Unsplash (but it’s not the actual bench).