40 Taking action

If critical theory is fundamentally about the way power operates in society to the benefit of some and to the detriment of others, then the response to this is not passivity and acquiescence, but action. As mentioned earlier, fighting to highlight the ways people marginalise, oppress, and silence others’ voices, and working to overturn asymmetrical power relations in society, lies at the heart of the critical theory project. And action has historically taken many forms, including street marches, academic social research, strikes and sit-ins, political lobbying, zines and posters, guerrilla activism, protest songs, visual arts, lectures and talks, courses and consciousness raising.

Consciousness raising is akin to Paulo Freire’s concept of ‘conscientization’ ^[1], in which education can free people from ‘the constraints of cultural silence’ ^[2]. Freedom comes with awakening of consciousness, by looking anew at the seemingly common sense and taken-for-granted realities of one’s life, and identifying how these are structured to perpetuate advantage for only a few. ‘Health activism’, Heather Came argues, ‘takes an overt political focus using both research and creative, unconventional methods to challenge the status quo’ ^[3]. And when this is applied to medical education and education research, it ‘can be a powerful means of changing how medicine is taught and whose voices are heard’ ^[4].

This activism not only targets the structural violence of sexism, racism and disablism, but also the people who have knowingly or unknowingly benefitted from perpetuating them. In critical disability studies, for instance, people’s use of stigmatising language in the media, the demeaning policies of politicians, and the lack of thought to good design by architects and town planners, have been particular targets. But by far the greatest level of condemnation has been directed at the health professionals, who have derived enormous social privilege and economic gain from practices of hierarchical ordering, normalisation, and othering, the design and use of stigmatising diagnostic labels, humiliating assessments, and painful treatments ^{[5][6][7][8][9]}. Liris Smith and colleagues recently expressed it this way;

‘Standardisation of medical practice emerged as the dominant biomedical approach to healthcare which also dissociated the human body from the reality of peoples’ lives and lived experience… the binaries of “normal”/“not normal”, and “well”/“not well” silenced diversity, including the social, cultural, and political factors that influence health’ ^[10].

There is a striking disjunction here, then, between the claims of health professionals to be working for disabled people, and the views of disabled people themselves. Critical disability activists have argued that through their medicalisation of all forms of ‘deviance’, and their work to return people to narrow, socially-mandated forms of ‘normal’, health professionals have worked hand-in-hand with the interests of industrial capitalism. Their alliances have been with the state and other orthodox professions, and not with disabled people. It is notable, for instance, as Ron Iphofen and Fiona Poland point out, that health professionals have traditionally sought to assert their professional principles through the pursuit of more professional autonomy and strengthening claims to reductive medical specialties, than by withdrawing their labour and campaigning seriously in support of the rights of their clients and patients ^[11].

In recent times, health professionals have been ‘called out’ for their self-interest and failure to speak up in the face of injustice. Tracy Blake writing in the British Journal of Sports Medicine (BJSM), for example, recently argued that those who have gained so much from working in sports and exercise medicine, including physiotherapists ^[12], have chosen to remain silent in the face of racism, colonialism and white supremacy, and this silence ’speaks volumes’ about the professions’ real concerns when it comes to athlete health, safety and well-being (ibid). Writing in response to the killing of George Floyd and the #blacklivesmatter campaign, she argued that the ‘The apathetic response from the BJSM to the laundry list of examples of institutionalised and interpersonal racism experienced by Indigenous and racialised people within sport around the globe has not gone unnoticed’ (ibid). Critically, Blake argues that this lack of response doesn’t ‘just happen’, but that, ‘They are predisposed to occur when there is a pattern of bias towards whiteness as the default’, and ‘[t]his is the foundational tenet of white supremacy’, that results from the ‘persistent dominance of older, White, cisgender male voices’ in the journal (ibid). ‘Racism will not fade into obscurity and irrelevance simply by people not being racist; it must be addressed through intentionally antiracist actions’ ^[13].

Throughout its history, physiotherapy has almost entirely ignored the social determinants of health and has no particular view on social justice, unlike professions like occupational therapy, nursing, midwifery, and psychology (for comparison, see the Psychologists for Social Change Manifesto here. It has done little, until recently, to formally acknowledge ‘racism, misogyny, homophobia, transphobia, ableism, ageism, classism, or religious bigotry’ ^[14]. And, perhaps most tellingly, it has never thought to articulate why it has ignored these for so long. Its strong belief in a person’s responsibility and a Protestant work ethic (see Chapter 5), appear to be tacit rejections of social, structural conditions that underpin people’s choices, which, perhaps, explains why physiotherapists have historically ignored critical theories? But such choices — if indeed they are deliberately ‘chosen’, are particularly problematic because, as Keith Tuffin has argued, they promote the belief that seemingly intractable, deeply structural, societal issues, are ’individually surmountable’ ^[15];

‘Our dominant model of personal, individualised services is wrong if it does not get to people living in São Paulo’s favelas, Bombay’s slums, Beijing’s underground cities, and Khayelitsha’s shanty towns, or to those surviving on Rosstat’s minimum consumer shopping baskets. It is in these spaces that most of the world’s one billion people with disabilities go about their lives’ ^[16].

Perhaps the Western health professions have simply argued that whilst they don’t deny that structural issues define many health problems, their focus is on the illness and injury that resides within the body, and their responsibility to return people back to ‘normal’. But if this is the case, professions like medicine and physiotherapy have been indoctrinated with what Robert Merton has called ‘an ethical sense of limited responsibility’ ^[17], and for more than a century extracted enormous capital from society for doing so.

And yet, Margrit Shildrick has argued that it is the non-disabled ‘who have the weightiest responsibility in the matter, not to speak on behalf of, or to pre-empt the experience of, others unlike themselves, but to interrogate precisely their own cultural and psychosocial location’ ^[18]. Jaris Swidrovich has recently called for the pharmacy profession to engage in ‘decolonization and indigenation’ ^[19]. Elizabeth McGibbon and her co-authors have described nursing as ‘ethically inadequate’ to ‘thinking about health and illness in the context of colonialism, globalization, pan-capitalism and environmental degradation’ ^[20]. Audiologist Mershen Pillay and Harsha Kathard have called for greater attention to the ‘underserved’ ^[21], while Kristen Abrahams has suggested speech-language pathology professionals need to give much more attention to social justice ^[22], a view echoed by Michelle Pentecost and Sadi Seyama in arguing for decolonised education ^[23][24]. Blythe Bell has recently described nursing education as an ‘oppressive educational climate for non‐white identifying people, a curriculum that does not attend to the social construction of difference, and a nursing culture that is not consciously situated in a broader sociopolitical context’ ^[25]. Cory Ellen Gatrall has gone further, suggesting that ‘since its inception, organized nursing has not only tolerated racism but also actively practiced it’ ^[26]. And so, ‘the operative word’ for critical theorists is ‘action’ ^[27]. So, what relevance does critical theory have for physiotherapists?