34 The conditions that made the health professions possible

In simple terms, then, the critical theories of the latter half of the twentieth century were studies in the way society had been structured by historical conflicts for power, that created benefits for some at the expense of others. And many of these focused on social institutions like the family, criminal justice, and healthcare, as sites where some of the most significant contests had taken place. Consider this summary from Raewyn Connell, for example;

’From its early stages in mercantile and agricultural capitalism, the new economic order depended on the regulation and destruction of bodies. This became notorious in the ‘industrial revolution’ of the 18th and 19th centuries. Engels’ Condition of the Working Class in England in 1844 is the most famous in a long series of reports that documented exhausting but tightly controlled labour in steam-powered factories, the coal mines that fuelled them, the cramped housing and polluted industrial cities that surrounded them. The process of extracting profit from other people’s labour, institutionalised on a grand scale in capitalism, was also a form of social embodiment. It was significantly gender-structured. Working-class men’s bodies were consumed—stressed, injured or worn out—in a process that constructs hegemonic masculinity in the working-class community and simultaneously creates profit for the employer. Colonialism created labour forces, in mines and plantations, in which such processes were at their most ferocious: Atlantic slavery, indentured migrant labour and forced Indigenous labour. The scale of death and impairment in a colonial enterprise like the silver mines of Potosí in the Andes, a main source of Spanish royal wealth, was worse than in any of Engels’ factories’ ^[1].

Note how Connell argues that the control and exploitation of the people’s work, the gendered division of labour, and the conquest of resources, can all be linked back to the Industrial Revolution and the birth of Western capitalism. But also, how Connell links capitalism to modern work, the creation of illness and injury, and the need to sustain a healthy workforce — all features that ought to be of particularly interest to physiotherapists. Shortly, I will look at three of the main fields of critical theory relevant to physiotherapy: gender, colonisation, and disability, but before this, I will briefly summarise a critical theory analysis of how the health professions came about.

In Chapter 3 I unpacked how the Industrial Revolution in 17th and 18th century Europe had transformed society, created the modern ideas of work, capitalism, and government. In the chapter, I also looked at the Marxian view that capitalism was the cause of a great deal of ill health. These ideas were already well understood by the critical theorists in the 1960s, but what they did was to uncover in much more detail how these systems and structures had worked.

The rapid industrialisation of food production, transportation, and communications, for example, put huge pressure on domestic supplies of land and human labour, and fed an insatiable demand for goods and services in the Global North. This led a new class of Europe’s avaricious industrialists to look overseas for ways to secure high-value foods, textiles, luxury goods, and cheap human labour. The race for resources, or ‘earth hunger’ ^[2], that this provoked, led to the colonial era, in which countries like Britain, Belgium, France, Germany, Japan, Portugal, Russia, and Spain, fought over entire countries, and forcibly enslaved whole populations in order to grow in wealth, and prestige.

Critical theorists have suggested that such naked acts of capitalist exploitation were welcomed by many, but also proved problematic for those in the emerging empires, who attempted to uphold the spirit of liberalism that had arrived with the Enlightenment. Liberalism argued that the ‘fate of every individual should be determined through their own efforts rather than by birth or heredity’ ^[3]; that all ‘men’ were created equal. But this clearly could not be true for those who lived in India, Brazil, or Sudan, whose bodies and land were seen as resources, available to whomever could colonise them. The answer came in the way the natural sciences were mobilised to explain the claimed superiority of the colonists.

The study of biology, ethnology, and zoology had become fascinations for explorers, who could now use the overseas trade to access worlds previously unknown to them. The colonial fascination with naming and categorising ‘exotic’ animals, plants and peoples (taxonomy), for example, spawned attempts to place all things in some form of natural order (Linneaus’s eighteenth century ‘nested hierarchies’, for example). Because this hierarchical ordering was based on the emerging principles of reason and logic that increasingly underpinned the natural sciences, the knowledge gained could be used to explain why some species appeared to be superior to others: humans ranked higher than animals, animals higher than plants, and plants higher than all other things.

But what was also increasingly clear to the new class of European colonists – or so it seemed – was that there were subdivisions within each of these classes, and that empirical evidence clearly indicated that because it was white, European, heterosexual, non-disabled men who were succeeding in their empire building, they must clearly represent the highest, and therefore most worthy, of all beings ^[4][5].

But while the new sciences could be mobilised to resolve the problem of the rights of all ‘men’, by providing empirical and theoretical ‘proof’ that some were more biologically and culturally superior to others, it could not fully address the moral problem of how to justify colonising another’s land and enslaving its people. And so, the colonists turned to the second major social discourse of the Enlightenment era — religion — for moral justifications for global expansion.

Most settler’s wanted peaceful acquiescence from the people they colonised, mainly because peaceful trade cost less, it was easier to maintain, and it fed the myth of the colonists’ natural racial superiority ^[6]. But no people can expect to practice land theft and slavery and expect it to be untroubled. And so while the might of European colonial power has been exercised with shocking frequency over the last four centuries, with war, internment, forced labour, rape, and torture all used as ‘deliberate and calculated’ methods to demean, discourage, demonise, ’displace and distance people from their land and resources’ ^[7], such actions were both expensive and morally problematic; not least because they suggested that white, European men were not as naturally superior as they had claimed to be.

One of the most powerful approaches taken drew directly from Western Enlightenment belief in the hierarchical ordering of species, however, and involved the deliberate construction of colonised people as different from, or ‘other’ than the European settlers. Sometimes, ‘others’ were given ‘positive’ terms (in the way the people of the Pacific were perceived to inhabit an unspoiled, Arcadian paradise on earth, for instance). But more often, others were seen as primitive, savage, uneducated, foreign, and godless ^[8]. Edward Said famously called this process ‘orientalisation’ ^[9], to describe the way dominant ‘occidental’ cultures developed cultural stereotypes of people, sometimes based on physical appearance (race) and sometimes on culture and custom (ethnicity), in order to justify claiming power over them.

One of the most important functions of ‘othering’ — to use Gayatri Spivak’s term ^[10] — was to create the image of an Indigenous culture needing to be saved: saved from its own primitive nature; saved from worshiping false idols; and even saved from a colonial culture that was so potent, that it might lead to their annihilation. Settlers argued that it would be in the interests of colonised peoples to join their colonisers rather than be trampled by them ^[11][12]. Missionary work became an important tool here, then because if colonised people could be brought into the flock, not only would their souls be saved, but their culture too. Matthew Fitzpatrick and Susie Protschky memorably called colonial missionary work a ‘ruthless benevolence’ ^[13], designed to support ‘hard’ colonisation with treaties and education, scientific evidence, bribery, new language, schooling and legal systems, training, manners and customs, inducements and promises, redesigned government, policing and surveillance; all designed with increasing sophistication by colonial powers as a way to support their economic interests ^[14].

Through these forms of ‘soft’ colonisation, colonial countries like Britain really ‘sought to have it all — an empire with key components founded on the mass dispossession of other people’s on the one hand, and a clean conscience on the other’ ^[15]. ‘Saving’ native races from the genocide that settlement inflicted on Indigenous peoples around the world, came to be seen as a charitable act conveying the manifest benefits of (Western) civilisation ^[16][17].

The work of colonisation takes enormous human labour, however; not only the kinds of manual labour needed to build roads and railways, buildings and bridges, but also to administer, count, prosecute, train, and maintain the new colony so that it will be efficient and profitable. Soldiers, missionaries, and scientists can only do so much of this work, and so the work of transposing the cultural capital of the mother country onto the new colony fell to a newly ‘enabling class’ of accountants and lawyers, planners and administrators, builders and engineers, doctors and nurses, who were often uncritically complicit in practices of soft colonisation.

At the heart of this enterprise was a two-way process of exchange, between the lessons learned after the early Industrial Revolution that could be taken to the colonies, and the lessons learnt from colonisation that could be brought back home. Practices of ‘othering’ so crucial for the orientalising project of colonisation ^[18], drew on the gendered division of labour that came with early capitalism. The biological sciences had long been mobilised to define women as less resilient and powerful than men, and their role in procreation, childbirth, and nurturing became increasingly demarcated, to the point that even by the late 18th century, early feminists like Mary Wolstencraft were arguing discrimination on the basis of gender was a breach of women’s basic human rights ^[19]. Wolstencraft argued that if natural scientists and liberal reformers were able to claim that our ability to reason set the human species apart from all other species, and all humans were capable of reason, denying women the right to education and work constituted an act of wilful discrimination ^[20].

Similarly, the hierarchical ordering of people along racial and gendered lines was supplemented by sciences that defined people by their ability, with those who were uneducated, illiterate, ill and injured, ‘simple’ or ‘handicapped’, being afforded the same ‘ruthless benevolence’ as Indigenous peoples. Darwinian concepts of natural selection, fed Francis Galton’s work on eugenics and statistics, and these, in turn, were fuelled by growing anxieties about racial weakness and declining male potency. Key here were the practices of normalisation that drew on the growing use of surveys, censuses, and epidemiological statistics as tools of European and North American governments ^[21]. The emerging class of enabling professions, particularly in the nineteenth century, drew heavily on statistical norms to distinguish those considered in need of diagnosis and treatment, arguing that the professional’s specialised knowledge justified them taking a leading role in ‘managing’ the population both at home and overseas.

Here we have, then, a template, drawn from critical theory principles, for how the healthcare professions became necessary as a response to the Industrial Revolution and the European capitalist expansion that ensued. Science provided the hierarchical ordering that justified the claims of superiority for white, European, male colonists. Its detached objectivity armed those in the Global North with the ability to strip people of their history and culture. Capitalism allowed people to be seen as cogs in a great machine, and bodies as modes of capital accumulation. Othering and orientalisation, when combined with epidemiological statistics, allowed for the new professional gaze of the dominant culture to fall on those who needed ‘treatment’ to bring them back to the fold (most especially women, Indigenous, and disabled people). Faith and enlightened liberalism provided all of the ‘soft’ powers of education, bureaucracy, therapy, and rehabilitation necessary to ensure people’s peaceful acquiescence. And the growing market for the trappings of affluence in the West created a demand for new forms of law and governance, buildings and infrastructure, trade and transportation, manufacturing and luxury goods, healthcare and education, that only the new professionals could provide.

Pillay and Kathard have written that the prestige and privilege of Western health professions ‘bear[s] testimony of our professions as products of a long history of slavery, colonisation and corporate capitalism’ ^[22]’, a sentiment echoed by Elizabeth McGibbon writing about Western nursing which, like physiotherapy, was ‘grounded in Western biomedical hegemony and its philosophical premises in positivism… as if families, communities or nations exist in these discrete, apolitical forms’ ^[23]. McGibbon suggests that the ‘facts and truths’ that underpin Western healthcare ‘are filtered through the lens of imperialist colonialism’, which sustains ‘conditions of social domination, limits autonomy and responsibility, and oppresses individuals and groups’ (ibid).

Perhaps it is not difficult to see, then, how the work of critical theorists could be used to critique physiotherapy and the historical and material conditions that have underpinned its development. There are perhaps three discrete areas within the massive body of critical theory work that emerged in the second half of the twentieth century,that pertain directly to physiotherapy: gender, colonisation, and disability. There are others besides, and this chapter will deal only with what have been called first- and second-wave critical theories, meaning those that concentrated on the identity politics that emerged around the struggles of women, racialised, Indigenous, and disabled people particularly between 1960 and 1990. The intersectional ‘turn’ that brought many of these discrete fields together will be looked at in Chapter 6. To begin with, then, we will consider how critical theorists came to see the health professions as gendered projects.