Outback Law & Order

Sound asleep a few nights ago, a rhythmic knocking sound woke me just before 1am.  It took me a while to register that this needed investigating and I eventually peeked through the bedroom blind.  I would never have seen the dark shadow hunched over on my front porch had s/he not been making such a racket trying to jimmy open my front door.  In my unnerved state I forgot the emergency number in favour of the non-urgent assistance line, whose automated system told me “If this is an emergency hang up now and dial 000”, which I promptly did.  They answered immediately with “Police, Fire or Ambulance?” and I was put through to a police line before I’d even spoken the word in full.

The next minute or so of my life went something like this:
“I am home alone and someone is breaking into my front door”
“What’s the address”
“<Address>…..  He’s gone quiet, I think he might already be inside!”
“Can you lock yourself in a room?”
“No there are no locks anywhere”
“Okay find somewhere to hide”
<Climbed into the wardrobe> “Okay I’m in the wardrobe”
“Stay on the line but don’t speak unless you have to.  I am here, the police are on their way, they shouldn’t take long.  You’re doing really well, the police know and they’re on their way, don’t hang up on me I’ll keep talking so that you know I’m here, you’re not alone and the police won’t be long, I am just letting them know that you are in the wardrobe…”
“<Whispering> I just saw a flash of a light”
“Are they in the bedroom with you?”
“I’m not sure”
“The police are going to arrive at any minute”.

I don’t believe I was in that wardrobe for longer than about two minutes when four uniformed officers arrived, knocking and shouting “Hello!  Police!”.  I climbed out of the wardrobe and opened the front door, relieved to learn the intruder had not succeeded to get inside.  Two policemen had jumped over my 6 foot front gate, frightening him into the back yard and losing him over the back laneway.

The 000 woman left me with the police and I am still thinking about her help that night, advising me based on what I told her was happening.  Had I not thought he was already in the house she would have advised that I turn on all lights, make noise and shout “the police are coming”.  Her ability to support me through a frightening few moments revealed someone well trained and highly skilled at her job.  There is no way of knowing who she is or where she was speaking to me from, so no way of thanking her.  This is not expected because she was doing her job, which it can be safely assumed she receives an acceptable living wage to do.

A female officer stayed with me while I calmed down; another went through the house to confirm no one was inside; two others scoured the yard where evidence of what had happened was collected.  The culprit had spent a significant amount of time at my back door, and only moved to the front door when he couldn’t get through the deadlock at the back.  The fact I had not heard anything while he was at the back likely made him assume no one was home.

An hour later various evidence had been taken, including fingerprints on both doors; I’d been led through the yard under an officer’s torchlight as he pointed out various clues such as a lighter, a water bottle, an open shed door; I’d given my statement; and I was assured they would be patrolling the area all night.  Cameras, iPads, torchlights, fingerprinting equipment; skilled teamwork and training to identify what had probably happened were all part and parcel of their excellent service.  I went back to sleep feeling safe and sound, unharmed, nothing having been stolen from me and not having to pay for any of the services that had just been spent on me.

This is another example of how we in wealthy countries are safe and cared for thanks to having such sound systems in place.  In most parts of the world, services with such levels of expertise, resources and skilled care for a complete stranger, do not exist and any attempt at providing a version of such a service comes at a cost to the provider on a user-pays basis.  In my world, citizens are valued and have a level of power and control we are not even conscious of, thanks to the strong systems which protect and respect us.

The difference is not cultural, but systematic.  When a country is left war-torn and not supported to full and proper recovery, then uneducated and amoral leaders have the chance to flourish.  This is happening in many countries around the world today, with millions of citizens suffering the long term consequences of wars, many of which ended decades ago.  Corruption established at the very top filters through every aspect of any system.  An example that I know of, is the way that government staff are paid unlivable wages (but guaranteed said wage until they die, which is more guarantee than most citizens have).  Applying for government positions costs a significant amount of money, with many taking loans, for the guarantee of a lifetime salary.  These fees filter up through the system, with higher level officials receiving the most benefit.  This largely explains why, when you visit a third world country, the rich-poor divide is so evident.  After years of living in Cambodia I have made some vague sense of these observations.

Earning an unlivable wage forces public servants to top up a number of different ways. One way is to have your own private business separate from your government employment.  This sees public servants spending minimal amounts of time at their government workplace, resulting in low quality of service in any government department.  Various user-pays demands are also made on anyone attending a government institution, such as a patient’s level of nursing care being determined by how much cash crosses their nurse’s palm at each encounter; school students required to pay a small daily cash fee to their teacher; police checkpoints where a fine with receipt will cost $X but if you don’t need a receipt you pay less; drivers licence applicants pay one fee for an exam with no guarantee of passing or a higher fee for a guaranteed pass; medical clinics and hospitals charge patients with no health literacy for treatments they don’t need.  The list of possibilities for corruption is infinite and a never-ending cycle of the poor indefinitely indebted in order to feed the rich.

A telephone number to call if you are in an emergency does not exist in most of the world, let alone one where skilled staff are on the other end of the line at the blink of an eye.  Four uniformed police turning up at one home within minutes of a reported break-in is an impossible fantasy, as is the idea that no cash or other benefit is required from the victim.  When my phone was stolen from me in Phnom Penh 8 months ago now, we attended a police station where a statement was written on letterhead for me which I was able to use for insurance purposes.  There was no talk of any investigation and local friends and colleagues all talked to me with the same theme: that the police often benefit from any robberies taking place in the area they patrol; they can be embroiled in, or even lead, robbery gangs; that I was lucky I didn’t have to pay cash for the statement; that usually locals don’t even report crime to the police because there is no level of trust in the system and a lot of suspicion and fear.  More than simply a lack of money, the real definition of poverty is a lack of protection.

Meanwhile the only follow up I can expect from the police – if any – is if they identify the person who attempted to enter my home the other night.  Any fingerprints they can lift will be placed into a computerised program and held indefinitely, so that if the culprit has never been fingerprinted yet, then it doesn’t mean he won’t be identified even years on from now.  Justice can’t be more complete than that and the world – for me – can’t be a fairer place.  If only everyone sharing the world with me could say the same.

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Developing a Global Identity

This article in The Economist (copy-pasted below) is well worth a read given the current state of world affairs.

We need a post-liberal order now

The international, rules-based system is collapsing. Overhauling it means combining national identity with a global ethos, says Yuval Noah Harari, a historian and author.

Open Future
September 26th 2018, by Yuval Noah Harari

For several generations, the world has been governed by what today we call “the global liberal order”. Behind these lofty words is the idea that all humans share some core experiences, values and interests, and that no human group is inherently superior to all others. Cooperation is therefore more sensible than conflict. All humans should work together to protect their common values and advance their common interests. And the best way to foster such cooperation is to ease the movement of ideas, goods, money and people across the globe.

Though the global liberal order has many faults and problems, it has proved superior to all alternatives. The liberal world of the early 21st century is more prosperous, healthy and peaceful than ever before. For the first time in human history, starvation kills fewer people than obesity; plagues kill fewer people than old age; and violence kills fewer people than accidents. When I was six months old I didn’t die in an epidemic, thanks to medicines discovered by foreign scientists in distant lands. When I was three I didn’t starve to death, thanks to wheat grown by foreign farmers thousands of kilometers away. And when I was eleven I wasn’t obliterated in a nuclear war, thanks to agreements signed by foreign leaders on the other side of the planet. If you think we should go back to some pre-liberal golden age, please name the year in which humankind was in better shape than in the early 21st century. Was it 1918? 1718? 1218?

Nevertheless, people all over the world are now losing faith in the liberal order. Nationalist and religious views that privilege one human group over all others are back in vogue. Governments are increasingly restricting the flow of ideas, goods, money and people. Walls are popping up everywhere, both on the ground and in cyberspace. Immigration is out, tariffs are in.

If the liberal order is collapsing, what new kind of global order might replace it? So far, those who challenge the liberal order do so mainly on a national level. They have many ideas about how to advance the interests of their particular country, but they don’t have a viable vision for how the world as a whole should function. For example, Russian nationalism can be a reasonable guide for running the affairs of Russia, but Russian nationalism has no plan for the rest of humanity. Unless, of course, nationalism morphs into imperialism, and calls for one nation to conquer and rule the entire world. A century ago, several nationalist movements indeed harboured such imperialist fantasies. Today’s nationalists, whether in Russia, Turkey, Italy or China, so far refrain from advocating global conquest.

“The world will then be divided into distinct nation-states, each with its own sacred identity and traditions.”

In place of violently establishing a global empire, some nationalists such as Steve Bannon, Viktor Orban, the Northern League in Italy and the British Brexiteers dream about a peaceful “Nationalist International”. They argue that all nations today face the same enemies. The bogeymen of globalism, multiculturalism and immigration are threatening to destroy the traditions and identities of all nations. Therefore nationalists across the world should make common cause in opposing these global forces. Hungarians, Italians, Turks and Israelis should build walls, erect fences and slow down the movement of people, goods, money and ideas.

The world will then be divided into distinct nation-states, each with its own sacred identity and traditions. Based on mutual respect for these differing identities, all nation-states could cooperate and trade peacefully with one another. Hungary will be Hungarian, Turkey will be Turkish, Israel will be Israeli, and everyone will know who they are and what is their proper place in the world. It will be a world without immigration, without universal values, without multiculturalism, and without a global elite—but with peaceful international relations and some trade. In a word, the “Nationalist International” envisions the world as a network of walled-but-friendly fortresses.

The key problem with the network of fortresses is that each national fortress wants a bit more land, security and prosperity for itself at the expense of the neighbors

Many people would think this is quite a reasonable vision. Why isn’t it a viable alternative to the liberal order? Two things should be noted about it. First, it is still a comparatively liberal vision. It assumes that no human group is superior to all others, that no nation should dominate its peers, and that international cooperation is better than conflict. In fact, liberalism and nationalism were originally closely aligned with one another. The 19th century liberal nationalists, such as Giuseppe Garibaldi and Giuseppe Mazzini in Italy, and Adam Mickiewicz in Poland, dreamt about precisely such an international liberal order of peacefully-coexisting nations.

The second thing to note about this vision of friendly fortresses is that it has been tried—and it failed spectacularly. All attempts to divide the world into clear-cut nations have so far resulted in war and genocide. When the heirs of Garibaldi, Mazzini and Mickiewicz managed to overthrow the multi-ethnic Habsburg Empire, it proved impossible to find a clear line dividing Italians from Slovenes or Poles from Ukrainians.

This had set the stage for the second world war. The key problem with the network of fortresses is that each national fortress wants a bit more land, security and prosperity for itself at the expense of the neighbors, and without the help of universal values and global organisations, rival fortresses cannot agree on any common rules. Walled fortresses are seldom friendly.

But if you happen to live inside a particularly strong fortress, such as America or Russia, why should you care? Some nationalists indeed adopt a more extreme isolationist position. They don’t believe in either a global empire or in a global network of fortresses. Instead, they deny the necessity of any global order whatsoever. “Our fortress should just raise the drawbridges,” they say, “and the rest of the world can go to hell. We should refuse entry to foreign people, foreign ideas and foreign goods, and as long as our walls are stout and the guards are loyal, who cares what happens to the foreigners?”

Humankind today faces three common problems that make a mockery of all national borders, and that can only be solved through global cooperation. These are nuclear war, climate change and technological disruption

Such extreme isolationism, however, is completely divorced from economic realities. Without a global trade network, all existing national economies will collapse—including that of North Korea. Many countries will not be able even to feed themselves without imports, and prices of almost all products will skyrocket. The made-in-China shirt I am wearing cost me about $5. If it had been produced by Israeli workers from Israeli-grown cotton using Israeli-made machines powered by non-existing Israeli oil, it may well have cost ten times as much. Nationalist leaders from Donald Trump to Vladimir Putin may therefore heap abuse on the global trade network, but none thinks seriously of taking their country completely out of that network. And we cannot have a global trade network without some global order that sets the rules of the game.

Even more importantly, whether people like it or not, humankind today faces three common problems that make a mockery of all national borders, and that can only be solved through global cooperation. These are nuclear war, climate change and technological disruption. You cannot build a wall against nuclear winter or against global warming, and no nation can regulate artificial intelligence (AI) or bioengineering single-handedly. It won’t be enough if only the European Union forbids producing killer robots or only America bans genetically-engineering human babies. Due to the immense potential of such disruptive technologies, if even one country decides to pursue these high-risk high-gain paths, other countries will be forced to follow its dangerous lead for fear of being left behind.

An AI arms race or a biotechnological arms race almost guarantees the worst outcome. Whoever wins the arms race, the loser will likely be humanity itself. For in an arms race, all regulations will collapse. Consider, for example, conducting genetic-engineering experiments on human babies. Every country will say: “We don’t want to conduct such experiments—we are the good guys. But how do we know our rivals are not doing it? We cannot afford to remain behind. So we must do it before them.”

Similarly, consider developing autonomous-weapon systems, that can decide for themselves whether to shoot and kill people. Again, every country will say: “This is a very dangerous technology, and it should be regulated carefully. But we don’t trust our rivals to regulate it, so we must develop it first”.

In order to survive and flourish in the 21st century, humankind needs effective global cooperation, and so far the only viable blueprint for such cooperation is offered by liberalism“.

The only thing that can prevent such destructive arms races is greater trust between countries. This is not an impossible mission. If today the Germans promise the French: “Trust us, we aren’t developing killer robots in a secret laboratory under the Bavarian Alps,” the French are likely to believe the Germans, despite the terrible history of these two countries. We need to build such trust globally. We need to reach a point when Americans and Chinese can trust one another like the French and Germans.

Similarly, we need to create a global safety-net to protect humans against the economic shocks that AI is likely to cause. Automation will create immense new wealth in high-tech hubs such as Silicon Valley, while the worst effects will be felt in developing countries whose economies depend on cheap manual labor. There will be more jobs to software engineers in California, but fewer jobs to Mexican factory workers and truck drivers. We now have a global economy, but politics is still very national. Unless we find solutions on a global level to the disruptions caused by AI, entire countries might collapse, and the resulting chaos, violence and waves of immigration will destabilise the entire world.

This is the proper perspective to look at recent developments such as Brexit. In itself, Brexit isn’t necessarily a bad idea. But is this what Britain and the EU should be dealing with right now? How does Brexit help prevent nuclear war? How does Brexit help prevent climate change? How does Brexit help regulate artificial intelligence and bioengineering? Instead of helping, Brexit makes it harder to solve all of these problems. Every minute that Britain and the EU spend on Brexit is one less minute they spend on preventing climate change and on regulating AI.

In order to survive and flourish in the 21st century, humankind needs effective global cooperation, and so far the only viable blueprint for such cooperation is offered by liberalism. Nevertheless, governments all over the world are undermining the foundations of the liberal order, and the world is turning into a network of fortresses. The first to feel the impact are the weakest members of humanity, who find themselves without any fortress willing to protect them: refugees, illegal migrants, persecuted minorities. But if the walls keep rising, eventually the whole of humankind will feel the squeeze.

In the 21st century we face global problems that even large nations cannot solve by themselves, hence it makes sense to switch at least some of our loyalties to a global identity“.

Yet that is not our inescapable destiny. We can still push forward with a truly global agenda, going beyond mere trade agreements, and stressing the loyalty all humans should owe to our species and our planet. Identities are forged through crisis. Humankind now faces the triple crisis of nuclear war, climate change and technological disruption. Unless humans realise their common predicament and make common cause, they are unlikely to survive this crisis. Just as in the previous century total industrial war forged “a nation” out of many disparate groups, so in the 21st century the existential global crisis might forge a human collective out of disparate nations.

Creating a mass global identity need not prove to be an impossible mission. After all, feeling loyal to humankind and to planet Earth is not inherently more difficult than feeling loyal to a nation comprising millions of strangers I have never met and numerous provinces I have never visited. Contrary to common wisdom, there is nothing natural about nationalism. It is not rooted in human biology or psychology. True, humans are social animals through and through, with group loyalty imprinted in our genes. However, for millions of years Homo sapiens and its hominid ancestors lived in small intimate communities numbering no more than a few dozen people. Humans therefore easily develop loyalty to small groups such as families, tribes and villages, in which everyone knows everyone else. But it is hardly natural for humans to be loyal to millions of utter strangers.

Such mass loyalties have appeared only in the last few thousand years—yesterday morning, on the timetable of evolution—and they coalesced in order to deal with large scale problems that small tribes could not solve by themselves. In the 21st century we face global problems that even large nations cannot solve by themselves, hence it makes sense to switch at least some of our loyalties to a global identity. Humans naturally feel loyal to 100 relatives and friends they know intimately. It was extremely hard to make humans feel loyal to 100 million strangers they have never met. But nationalism managed to do exactly that. Now all we need to do is make humans feel loyal to 8 billion strangers they have never met. This is a far less daunting task.

It is true that in order to forge collective identities, humans almost always need some threatening common enemy. But we now have three such enemies: nuclear war, climate change and technological disruption. If you can get Americans to close ranks behind you by shouting “the Mexicans will take your jobs!” perhaps you could get Americans and Mexicans to make common cause by shouting “the robots will take your jobs!”.

That does not mean that humans will completely give up their unique cultural, religious or national identities. I can be loyal at one and the same time to several identities—to my family, my village, my profession, my country, and also to my planet and the whole human species.

It is true that sometimes different loyalties might collide, and then it is not easy to decide what to do. But who said life was easy? Life is difficult. Deal with it. Sometimes we put work before family, sometimes family before work. Similarly, sometimes we need to put the national interest first, but there are occasions when we need to privilege the global interests of humankind.

What does all that mean in practice? Well, when the next elections come along, and politicians are asking you to vote for them, ask these politicians four questions:
* If you are elected, what actions will you take to lessen the risks of nuclear war?
* What actions will you take to lessen the risks of climate change
* What actions will you take to regulate disruptive technologies such as AI and bioengineering?
* And finally, how do you see the world of 2040? What is your worst-case scenario, and what is your vision for the best-case scenario?

If some politicians don’t understand these questions, or if they constantly talk about the past without being able to formulate a meaningful vision for the future, don’t vote for such politicians.

Yuval Noah Harari is a history professor at Hebrew University of Jerusalem and the author of three best-selling books, “Sapiens: A Brief History of Humankind” (2014) and “Homo Deus: A Brief History of Tomorrow” (2016). His most recent book is “21 Lessons for the 21st Century” published in August.

Copyright © Yuval Noah Harari 2018

Of Children and Fish

Two weeks ago I made a rushed five day visit to Cambodia between study commitments.  Here are a few of the most interesting snippets of my week.

From the airport we went straight to Thomas House, a small NGO run by a retired Australian couple on the outskirts of the city.  Running off the smell of an oily rag in an impoverished slum area, they offer a basic health clinic and refuge for neighbourhood children to access a meal and a safe place to play, albeit in mud beside a busy road with rats sauntering around.

They are currently helping a 10 year old with a severe case of ichthyosis.  This condition causes dry, scaly, thickened and cracked skin.  The unsightly overgrowth of skin has led to his eyes being pulled permanently open, with permanent vision loss in one blank-staring eye and the other expected to render him completely blind within a couple of months unless specialist care can be made available.  He and his young father are staying at Thomas House in order to access specialist services in the city, which they can only afford thanks to the fundraising efforts of Thomas House.  Dad is also being taught how to treat the skin with exfoliants and moisturisers, again only affordable thanks to Thomas House.  The Khmer specialist involved has contact with overseas specialists and the family have had Skype consultations with America, Australia and the UK, generating much interest in the medical world apparently.

As well as spending time at Thomas House, learning how they work and some of the neighbourhood issues, we delivered a toy car set to the little boy who is badly teased and excluded by the other children.  They reported that he slept with his cars that night.

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Baby with Ichthyosis

The following day we started at Kung Future who were organising school uniforms for the new school year. With the river so high, the Cham peoples’ boats were moored right at the sidewalk, metres above where we usually have to climb down into their muddy community.  Organised chaos reigned as many dozens of different-sized school uniforms had to be dispensed in some way.

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Kung Future delivering school uniforms to landless fisher children in Phnom Penh  https://kungfuture.org/

From there we headed across to the other edge of the city to visit a couple of other families including the lady whose broken leg had left her destitute with three children and who my housemate and I raised funds for last year so she could have the surgery she needed while keeping her children in school.  Then the family of grandmother, two sets of parents and five young children living in a wooden shack two steps above ground with holes in the ceiling for the rain to fall through and holes in the floors for the children to fall through.

At lunch time we headed in yet another direction, finding a little crooked restaurant for $2 lunch of rice and chicken.  We then arrived for our appointment at the Liger Leadership Academy where a New Zealand friend working there had organised a tour for us.  Two young students with impeccable English and full of hope guided us through the large grounds, well resourced classrooms and stylish residential facilities, talking at length about the school’s mission and project-based teaching style.  We then joined a small class of eight students approximately 15 years old, undertaking a project about the Cambodian health system, for a Q & A session they invited us to after hearing of our visit.

As our hour-long Q & A came to an end Wat Opot called to say they were waiting to pick us up.  The Wat Opot children, unless there is no option, go home in the school holidays and our three Kampong Cham boys were waiting to say hello before leaving to spend their holidays with an uncle.  More than six months since we had seen them, they were all taller, bigger and different.  Reportedly nervous about seeing us, it didn’t stop them from greeting us excitedly with big hugs before disappearing in a crowded tuk tuk.

That evening was spent soaking up the joy of Wat Opot, including their melting pot of volunteers, the children, the routine of meals, play, meditation and bed time, when the staff and volunteers joined us for a catch up in the volunteer dorm area.  The next morning they were delivering the next set of children home for the holidays, and we were squeezed in amongst the crowds to be delivered en route for our trip south to Kep.

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Wat Opot Children’s Community vehicle delivering various humans to various locations

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My suitcase perched amongst crowds on the tray back

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Wat Opot convoy delivering kids to family for the holidays

After locating a couple of remote villages and signing children out for the holidays to extended family, we stopped on a busy corner and they offloaded us.  My Khmer travel companion negotiated with what seemed like a million taxi touts until we found one going in the right direction for the right price.  We found a vendor under a dusty canopy, plastic chairs and tin table teetering on sloping mud, offering chicken and rice for breakfast.  The driver waited while we ate, then led us to his mini van, with two seats left, heading about an hour south to Kep.

Kep was time to relax and we spent our days breathing in salty air, strolling alongside the Kampot river, eating seafood, watching fishers, visiting a hillside pagoda and abandoned French estates and generally feeling like we were actually on holiday!

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Governor’s estate in Kep.  Bullet holes in the wall from the Khmer Rouge battles that raged here nightly up until as recently as 2000.

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One of the many abandoned French homes around Kep

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Watching the fisher people from Kep’s Crab Market

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This guy waded from the shore to his boat in head-high waters, waves crashing over him as he occasionally disappeared entirely except for one arm devotedly held high into the sky protecting five coffees hanging from his wrist.  He climbed back on board unnoticed by his workmates but for the safely delivered coffee.

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Thatched wooden Khmer style hut accommodation in Kep

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An unexpected housemate

It is exactly fourteen weeks until my longer-term return to Cambodia.

The Danger of a Single Story

Chimamanda Ngozi Adichie is a Nigerian novelist I had not heard of today, when I heard her speak at a TED Talk, named “The danger of a single story”.  A few excerpts are written below.  The 18 minute talk, well worth hearing, is linked underneath.

I would like to tell you a few personal stories about what I like to call “the danger of the single story”.  I thought about this when I left Nigeria to go to university in the United States.  I was nineteen.

My American room mate was shocked by me.  She asked where I had learned to speak English so well and was confused when I said that Nigeria happened to have English as its official language.  She asked if she could listen to what she called my “tribal music”, and was consequently very disappointed when I produced my tape of Mariah Carey.

So after I had spent some years in the US as an African, I began to understand my room mate’s response to me.  If I had not grown up in Nigeria, and if all I knew about Africa were from popular images, I too would think that Africa was a place of beautiful landscapes, beautiful animals, and incomprehensible people, fighting senseless wars, dying of poverty and AIDS, unable to speak for themselves, and waiting to be saved by a kind, white foreigner.

So that is how to create a single story.  Show a people as one thing, as only one thing, over and over again, and that is what they become.  I recently spoke at a university where a student told me that it was such a shame that Nigerian men were physical abusers like the father character in my novel.  I told him that I had just read a novel called “American Psycho” and that it was such a shame that young Americans were serial murderers.

It would never have occurred to me to think that just because I had read a novel in which a character was a serial killer, that he was somehow representative of all Americans.  This is not because I am a better person than that student, but because of America’s cultural and economic power, I had many stories of America.  I had read Tyler and Updike and Steinbeck and Gaitskill.

I did not have a single story of America.

I’ve always felt that it is impossible to engage properly with a place or a person without engaging with all of the stories of that place and that person.

The consequence of the single story is this:

It robs people of dignity.

It makes our recognition of our equal humanity difficult.

It emphasises how we are different, rather than how we are similar.

Stories matter.

Many stories matter.

Stories have been used to dispossess and to malign.  But stories can also be used to empower and to humanise.  Stories can break the dignity of a people, but stories can also repair that broken dignity.

I don’t write fiction but I do write stories about other people as I see them.  The main purpose of this blog has always been to give insight into the lives of people who do not have much, if any, voice of their own.  That includes indigenous Australians who in my experience are assigned a single story by mainstream Australia which serves to malign and disempower; and people in other countries where I have learned so much about myself, from their experiences of the world which differ so much from my own.

Chimamanda is a beautiful speaker and her full speech is well worth hearing:

Chimamanda

The danger of the single story

Babies Are Beautiful

My latest Child Health essay was about Attachment.  It may sound boring but in fact, it’s an intriguing subject worth sharing.  We were all once in need of attachment to someone and for all of us, it played out in an imperfect way, affecting who we are today.

Assignment 3: Principles and application of attachment theory

Scenario Three: During a health check for six-month-old Phoebe you notice a mild delay in her motor skills. Her mother speaks of her with a sense of frustration, indicating that Phoebe is so dependent on her, that she is bored and feels isolated compared to her lifestyle before the pregnancy. You are aware that this mother had a difficult labour, that resulted in a caesarean section delivery.

Healthy development, crucial to an infant’s life-long cognitive, socio-emotional and physical health outcomes, is intrinsically linked to the quality of the infant’s attachment with a primary caregiver4, 18.  The infant brain grows most rapidly and is in its most pliable state from the prenatal period into the first three years, when the foundations of neurobiological architecture and processes are being laid6, 20.  Healthy growth and development relies on the timing, nature and patterns of external experiences26, which impact on a child’s social, emotional and academic success throughout life27.

Sensitive and consistent caregiver interactions are required for healthy psychological and physical development6, but infant attachment to the primary caregiver occurs regardless of the quality of care, including when neglect or abuse are involved30.  Positive early caregiving experiences promote healthy brain development while negative early experiences that may be threatening, uncertain, neglectful or abusive, over-activate the stress response system, affecting neurobiological processes and causing a disruption to development which can result in lifelong negative emotional and cognitive outcomes17, 30.

Factors that play a role in the caregiver-infant attachment process include but are not limited to genetics, family income, family size, parental age, education and mental health, marital relationships, social support systems, life stressors and social adversity14.  The impact that early years experiences have on the developing infant’s quality of attachment and the implications for Maternal Child and Family Health (MCaFH) Nurse practice will be discussed herein with a focus on Scenario 3.

John Bowlby formulated the first comprehensive theories of attachment in the late 1950s and early 1960s and his work was built upon by a number of others, notably Mary Ainsworth and John Robertson31.   Apart from physical attachment via the umbilical cord, newborn babies are unattached but physically dependent for all of their needs24.  There is a biological predisposition to form emotional attachments11 which become established during the first two years of life through a number of phases16.

Referencing Mary Ainsworth’s Strange Situation Procedure, Mares et al18 describe the four different attachment behaviours which manifest in children when faced with a specific range of stressors.  These attachment patterns are categorized as “secure” (seen in children who have experienced consistent and predictable caregiving); “insecure/avoidant” and “insecure/ambivalent” (both considered normal variants and seen in children who have anxieties about the availability of their caregiver); and “disorganized” (considered pathological and seen in children who have experienced distress and/or fear from their primary caregiver).  Children with secure attachment are considered most likely to have positive long-term outcomes in terms of social, emotional and cognitive wellbeing18, while children with disorganized attachment are more likely to experience negative long-term outcomes30, 11.

Individual children will present with different attachment patterns based on interrelating factors such as genetic predisposition, specific external experiences, age at which and frequency with which the experiences occur26, 6, 27, 25.  Appendix 1 provides a diagrammatic overview of the Circle of Security8 showing the characteristics of secure attachment whereby an infant experiences a safe haven (comforting caregiving responses); secure base (reliable and consistent caregiver); proximity maintenance (the caregiver is nearby while the child explores his/her world); and separation anxiety (the child expresses sorrow when separated from the caregiver)5.

As argued by Staples29, evidence about the impact that caregiving attachment has on long-term outcomes for infants highlights the need for early assessment and multidisciplinary intervention with appropriate support, care and education being a crucial role of the MCaFH Nurse.  Effective communication, establishing and maintaining respectful, professional, therapeutic relationships with children, caregivers and families using a strengths-based approach are included in the required standards of practice for the MCaFH Nurses in Australia15.

The role of the MCaFH Nurse is complex but Fraser et al13 identified key practice areas as being: “child growth and development; maternal mental health; information provision to support behaviour/attitudinal change; and building parent capacity”, by establishing therapeutic relationships with clients, utilizing skills including enhanced communication, reflective practice, emotional intelligence and empathy.

Appendix 227 provides a diagrammatic view of age-dependent functional development of different parts of a human infant’s brain, showing that this infant with delayed motor skills may have some disruption of cerebellar development.  MCaFH Nurse practice includes the use of “standardized, evidence-based assessment tools3.  An example of this is the NT Government Department of Health Child and Family Health Clinical Practice Manual (2016) (see Appendix 3a).  To ensure appropriate assessment and diagnosis, a full physical assessment, growth monitoring, physical development monitoring, sleep, nutrition and toileting patterns and/or concerns should be undertaken.  Socioemotional and cognitive assessment are also required, and referral to other services as appropriate3.

Early intervention is imperative to positively alter the infant’s developmental course and enhance her long-term outcomes22.  The NT Government Department of Health Child and Family Health Clinical Practice Manual (2016) outlines legislation requiring that MCaFH Nurses obtain informed consent from the child’s legal guardian before making a referral to another service (see Appendix 3b).  In this scenario a referral to Occupational Therapy is recommended for specialized early intervention of the infant’s motor skills delay23.  Using a reference tool such as the Ages and Stages Questionnaire, described in Appendix 41, or the Red Flags Early Identification Guide7 will assist the MCaFH Nurse to facilitate discussion with the mother (and father or other caregivers as appropriate), to ensure informed consent and participation in all recommended interventions including referral to other services.

As recommended by the Australian Health Minister’s Advisory Council2, during individual consultation with the infant and her mother, the MCaFH Nurse should offer health education, anticipatory guidance and information for parental skill development based on their individual assessment and needs.  This includes advice, support and referral for both the infant and the mother’s needs.  Zanardo et al31 found a significant correlation between emergency caesarian section delivery and negatively altered mother-infant bonding experiences, which will be a significant consideration in this scenario.  Women commonly feel unprepared for their transition to motherhood, lack confidence in parental skills and experience stress, distress and postnatal depression2.  As discussed above, these factors may all affect the infant’s healthy development and indicate a need for early intervention.  Providing a safe place for this mother to express her feelings and using a standardized assessment tool such as the Edinburgh Postnatal Depression Scale (EPDS)8 will allow the MCaFH Nurse to assess the mother’s needs, offer advice and guidance in a non-judgmental and supportive environment, and consider options for appropriate follow up and/or referral.

Depending on the EPDS score, it may be appropriate to refer the mother to a General Practitioner for further mental health care.  There is mixed evidence of the effectiveness of home visits to children and families at risk10.  However, Center on the Developing Child5 recommend coaching of parents should take place in a wide variety of settings, including home visits.  The Australian Health Minister’s Advisory Council2 describe intuitive and anecdotal evidence that the MCaFH Nurse could provide support to this family in their home for a more complete assessment of the situation and perhaps more contextualized advice and support, involving the father, extended family or other caregivers and support people.

In this scenario the MCaFH Nurse must make an assessment of mother-infant interactions, to ensure appropriate interventions are based on individual circumstance and need.  Intervention should involve promoting age-appropriate play and communication to encourage sensitive and nurturing responses of the mother to her child’s needs, not only improving the child’s external experiences but also the mother’s mental health, leading to an improved dyadic relationship9.  An example of standardized resources available for use in this scenario is the Ages and Stages tool which offers age-specific developmental information and ideas for activities to promote development in communication, fine and gross motor skills, problem solving and personal/social skills (see Appendix 4)1.

Encouraging involvement of the father or other caregivers is an important part of the process, as evidence shows infants have better cognitive outcomes when their fathers are actively involved27.  Linking the family into support systems such as play groups, Circle of Security sessions18 or Families as First Teachers20, would give the infant opportunities for stimulation and the mother a chance for social contact with others experiencing similar transitions to parenthood, as well as a range of useful information to implement on a practical level to improve the attachment process.  It may also be appropriate to provide links to relevant websites offering practical and supportive information, such as www.raisingchildren.net.au.

The common connection throughout the interventions discussed in this scenario is a MCaFH Nurse service that is able to establish and maintain a therapeutic relationship with the family.  This requires a range of specialized skills to promote parental skill and confidence, support the needs of both mother and infant, ensure timely intervention for optimum long-term outcomes, and collaborate with a multi-disciplinary team of specialists and allied health professionals.

References

  1. Australian Government Department of Health (updated 20 May 2013). National Framework For Universal Child and Family Health Services, Appendix 3: Tools to assist in health surveillance and monitoring.  Retrieved from http://www.health.gov.au/internet/publications/publishing.nsf/Content/nat-fram-ucfhs-html~appendices~appendix3
  2. Australian Health Minister’s Advisory Council (2011). National Framework for Universal Child and Family Health Services.  Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/AFF3C1C460BA5300CA257BF0001A8D86/$File/NFUCFHS.PDF
  3. Barker, D, Barker, M, Fleming, T, Lampl, M (11 December 2013). Developmental biology: Support mothers to secure future public health, Nature International weekly journal of science, Vol. 504, Issue 7479, p. 209
  4. Bowlby, J (1982). Attachment and Loss, Volume 1 Attachment, Second Edition, Basic Books, New York.  Retrieved from https://pdfs.semanticscholar.org/0cf3/524fa9a2f7989eaa64cf8f094d3182add3c7.pdf
  5. Center on the Developing Child (2007). The Impact of Early Adversity on Child Development (In Brief).  Retrieved from developingchild.harvard.edu
  6. Child Development Program and Brisbane North Primary Health Network (July 2016). Red Flags Early Identification Guide for children aged birth to five years, Second Edition.  Retrieved from https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/red-flags-a3.pdf
  7. Circle of Security Network (2013). Circle of Security®: Parent Attending to Child’s Needs.  Retrieved from http://circleofsecuritynetwork.org/files/A%20Circle%20of%20Security.pdf
  8. Cox, JL, Holden, JM, Sagovsky, R (June 1987). Detection of postnatal depression.  Development of the 10-item Edinburgh Postnatal Depression Scale, British Journal of Psychiatry, Vol. 150, pp. 782-786.  Retrieved from https://www.blackdoginstitute.org.au/docs/default-source/psychological-toolkit/edinburgh-postnatal-depression-scale.pdf?sfvrsn=8
  9. Daelmans, B, Black, M, Lombardi, J, Lucas, J, Richter, L, Silver, K, Britto, P, Yoshikawa, H, Perez-Escamilla, R, Macmillan, H, Dua, T, Bouhouch, R, Bhutta, Z, Darmstadt, G L & Rao, N (14 September 2015). Effective interventions and strategies for improving early child development, British Medical Journal, Vol. 351. pp. 23-26
  10. Doyle, C, Cicchetti, D (June 2017). From the Cradle to the Grave: The Effect of Adverse Caregiving Environments on Attachment and Relationships Throughout the Lifespan, Clinical Psychology Science and Practice, Vol.24, No.2
  11. Doyle, O (July 2017). The First 2,000 Days and Child Skills: Evidence from a Randomised Experiment of Home Visiting, Life Course Centre Working Paper Series, No. 2017-13.  Retrieved from http://www.lifecoursecentre.org.au/wp-content/uploads/2017/07/2017-13-LCC-Working-Paper-Doyle.pdf
  12. Fraser, S, Grant, J, Mannix, T (December 2016). Maternal Child and Family Health Nurses: Delivering a Unique Nursing Speciality, Maternal and Child Health Journal, Vol. 20, Issue 12, pp 2557-2564
  13. Gervai, J (2009). Environmental and genetic influences on early attachment, Child and Adolescent Psychiatry and Mental Health, Vol. 3, No. 25.  Retrieved from https://capmh.biomedcentral.com/articles/10.1186/1753-2000-3-25
  14. Grant, L, Mitchell, C, Cuthbertson, L (2017). National Standards of Practice for Maternal, Child and Family Health Nurses in Australia, Adelaide, Flinders Press
  15. Institute for Learning and Brain Sciences (2012). Phases of Attachment Development, University of Washington.  Retrieved from http://modules.ilabs.uw.edu/module/development-of-attachment/449-2/
  16. Jordan, B (August 2014). An overview of attachment theory, Community Paediatric Review, Current issues in children’s health and development, The Royal Chlidren’s Hospital Melbourne.  Retrieved from https://www.rch.org.au/uploadedFiles/Main/Content/ccch/CPR_Vol22_No3.pdf
  17. Mares, S, Newman, L, Warren, B (2011). Clinical Skills in Infant Mental Health: The First Three Years.  Retrieved from https://search-informit-com-au.ezproxy.flinders.edu.au/fullText;dn=283546165841039;res=IELHEA
  18. Mercer, J (2015). Examining Circle of SecurityTM: A Review of Research and Theory, Research on Social Work Practice, Vol 25, No. 3, pp 382-392.  Retrieved from http://journals.sagepub.com.ezproxy.flinders.edu.au/doi/pdf/10.1177/1049731514536620
  19. Newman, L, Judd, F, Olsson, CA, Castle, D, Bousman, C, Sheehan, P, Pantelis, C, Craig, JM, Komiti, A, Everall, I (2016). Early origins of mental disorder – risk factors in the perinatal and infant period, BMC Psychiatry, Vol. 16, No. 270.  Retrieved from https://link.springer.com/article/10.1186/s12888-016-0982-7
  20. NT Government Department of Education (last updated November 2017). Families as First Teachers.  Retrieved from https://education.nt.gov.au/education/support-for-teachers/faft
  21. Oberklaid, F, Drever, K (September 2011). Is my child normal?  Milestones and red flags for referral, Australian Family Physician, Vol. 40, No. 9.  Retrieved from https://www.racgp.org.au/download/documents/AFP/2011/September/201109oberklaid.pdf
  22. Occupational Therapy Australia (2016). Occupational Therapy Guide to Good Practice: Working with Children.  Retrieved from http://www.otaus.com.au/sitebuilder/advocacy/knowledge/asset/files/87/guidetogoodpractice-workingwithchildren[may2016]-finalweb.pdf
  23. Perry, B (October 2001). Keep the Cool in School: Attachment – The First Core Strength, Early Childhood Today.  Retrieved from https://www.scholastic.com/teachers/articles/teaching-content/keep-cool-school-attachment-first-core-strength/
  24. Perry, B, Szalavitz, M (2007). The Boy Who Was Raised as a Dog And Other Stories From a Child Psychiatrist’s Notebook, Basic Books, New York
  25. Perry, B, Szalavitz, M (March 2010). Born For Love, HarperCollins e-books
  26. Rowley, S, Williams, J (2015). Research Review Educational Series, Multi-sensory stimulation and infant development.  Retrieved from https://www.researchreview.co.nz/getmedia/309bffda-42ba-4b5c-9e32-a170bf1cf3d2/Educational-Series-Multisensory-Stimulation-and-infant-development_1.pdf.aspx?ext=.pdf
  27. Sethna, V, Perry, E, Domoney, J, Iles, J, Psychogiou, L, Rowbotham, NEL, Stein, A, Murray, L, Ramchandani, PG (May-June, 2017). Father-child interactions at 3 months and 24 months: Contributions to children’s cognitive development at 24 months, Infant Mental Health Journal, Vol. 38, Issue 3, pp. 378-390
  28. Staples, J (June 2016). Neuroscience research into infant mental health: the impact on child and family health nursing policy and practice, Australian Journal of Child and Family Health Nursing, Vol. 13, Issue 1
  29. Sullivan, RM (August 2012). The Neurobiology of Attachment to Nurturing and Abusive Caregivers, The Hastings Law Journal, Vol. 63, No. 6, pp 1553-1570
  30. Van der Horst, FCP (2011). John Bowlby – From Psychoanalysis to Ethology, Unraveling the Roots of Attachment Theory, Wiley-Blackwell
  31. Zanardo, V, Soldera, G, Volpe, F, Giliberti, L, Parotto, M, Giustardi, A, Straface, G (24 May, 2016). Influence of elective and emergency cesarean delivery on mother emotion and bonding, Early Human Development, Vol. 99

Appendix One: Circle of Security

Circle of Security

Circle of Security Network 2013

Appendix Two: Age-Dependent Brain Development

Brain Areas Pic

Rowley and Williams (2015)

 

Pessimism and Privilege

Pessimism and Privilege

Partners in Health was formed by Dr Paul Farmer and some peers including Roald Dahl’s daughter Ophelia, in the late 1980s after Farmer became determined to make a difference to the people he met in Haiti as a medical student.

The success of Partners in Health in places as far flung as Haiti, Russia and Rwanda, is proof that optimism combined with love, focus and action, makes incredible difference.

Global health statistics available through many organisations such as The Gates Foundation and UNICEF confirm that to be on the right side of history, you really need to take an optimistic and informed view of what is actually happening in this era of progress.

The same can be said for indigenous health here in Australia.  When a colleague said recently “what is the point of what we do because nothing is changing”, I was surprised and a little disturbed, as I pondered on the information available to us through many sources that in fact, as difficult as things continue to be, strides of improvement are well documented, well known and deserve to be celebrated.

If you’re privileged enough to express pessimism about the point of helping others, you’re privileged enough to access the plethora of information that justifies optimism.

This I Believe – Dr Paul Farmer:

I believe that health care is a human right.

I have worked as a doctor in many places and I have seen where to be poor means to be bereft of rights.

I saw early on, still just a medical student, the panicky dead-end faced by so many of the destitute sick.  A young woman dying in childbirth.  A child writhing in the spasms of a terrible disease for which a vaccine has existed for more than a century.  A friend whose guts were irreparably shredded by bacteria from impure water.  An 8 year old caught in crossfire.

“What a stupid death”, goes one Haitian response.

Fighting such stupid deaths is never the work of one, or even of a small group.  I’ve had the privilege of joining many others providing medical care to people who would otherwise not be able to get it.  The number of those eager to serve is impressive and so is the amount that can be accomplished.

I believe that stupid deaths can be averted.  We’ve done it again and again.  But this hard and painful work has never yet been an urgent, global priority.  The fight for health as a human right, a fight with real promise, has so far been plagued by failures.

Failure because we’re chronically short of resources.

Failure because we’re too often at the mercy of those with the power and money to decide the fates of hundreds of millions.

Failure because ill health, as we’ve learned again and again, is more often than not, a symptom of poverty and violence and inequality.  And we do little to fight those when we provide just vaccines, or only treatment for one disease or another.

Every premature death, and there are millions of these each year, should be considered a rebuke. 

I know it’s not enough to attend only to the immediate needs of the patient in front of me.  We must also call attention to the failures and inadequacy of our own best efforts.  The goal of preventing human suffering must be linked to the task of bringing others, many others, into a movement for basic rights.

The most vulnerable; those whose rights are trampled; those rarely invited to summarise their convictions for a radio audience, still believe in human rights, in spite of or perhaps because of, their own troubles.

Seeing this in Haiti and elsewhere has moved me deeply and taught me a great deal.  I move uneasily between the obligation to intervene and the troubling knowledge that much of the work we do, praised as humanitarian or charitable, does not always lead us closer to our goal.  That goal is nothing less than the refashioning of our world into one in which noone starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended.

Of course such a world is a utopia and most of us know that we live in a dystopia.  But all of us carry somewhere within us, the belief that moving away from dystopia moves us towards something better and more humane.

I still believe this.