The People's Cries

About domination and its effects: and about resistance to exploitation and abuse through solidarity.

For Intersectional Solidarity – review of Lola Olufemi, “Feminism, Interrupted. Disrupting Power.”


With our oppressors uniting, it’s increasingly clear that all our struggles for            freedom are interconnected, and that no one will be free until we are all free.
                  Angela Davis, writing about her solidarity with Palestinian BDS campaigners, for     this year’s Israeli Apartheid Week.
Lola Olufemi’s new book, “Feminism, Interrupted – Disrupting Power” declares itself from the start as arguing “for the abolition of all prevailing systems of violence.” The way that ambition is expressed fits into the moral and political framework that I have been striving to articulate for years in this blog and elsewhere, in which acts which affect others’ lives (that enact power) are judged according to their anticipated health effects. Health (or good) – of individuals, households, neighbourhoods, cities, ecosystems – is like communism in that it cannot ever be fully achieved, since life damages us all and we all die. Yet it can be put forward as the aim of political struggle to create a society in which people’s capacity to damage other people is minimised, and more widely, a sustainable ecology is created, in which destruction, waste and pollution and abuse of other creatures is minimised.

The gap between politics and public health – so brutally exposed by the Covid-19 pandemic – is associated with the hegemonic ideology in which abuse, domination, bullying, coercion, that is, systems of negative power – are accepted as the prevailing structuring forces in social systems, to the extent that they become unseen, or even valued as bulwarks against chaos. The exercise of power – negative power that stems ultimately from violence – seeks to damage the health of those upon whom it is acted, even if only by limiting their own capacity to act. The phrase ‘systems of violence’, obviously includes the building and maintaining of walls – prison walls, borders, factory walls – it is not just overt violence.  Also, as the Black Lives Matter struggle shows us only too clearly, the judicious repetition of past horrific excesses of violence is key to their maintenance – capitalism still depends upon the methods of its ‘primitive accumulation’ such as slavery and dispossession out of which it was founded. The literature on the different forms child abuse can take suggests also that neglect has to be included as part of such systems, such as the ‘organised abandonment’ of the poor, the disabled and the stigmatised that constitutes austerity. (Ruth Wilson Gilmore, 2020, podcast for Haymarket Books).

Olufemi promotes a feminism that struggles against the ‘sexist’ State which has led attacks on women; a feminism that is anti-imperialist – not just against militarism but against incarceration and police violence, and against all forms of racism, including the patronising ‘rescue’ of Muslim women that she terms ‘the Saviour Complex’; a feminism that stands firm against trans-misogyny; and a feminism that is against body shaming. She makes a moving call for a food politics that is centred on providing nourishment for our selves and others. This capacity for nourishment, of which the power exerted by a mother over her nurtured infant might be an archetype, is a positive kind of power that enhances the health of its agents and recipients. Other activities such as much domestic labour, education and care work also involve this kind of power, though it is mostly hidden within structures and institutions that are integrated into the systems of coercive domination – doctors’ surgeries, hospitals, schools, universities, care homes, the patriarchal nuclear family, inheritance and the like – that is, nurture refers to the existence of some kinds of power than we need to value, and disentangle from their pollutants, rather than simply oppose.  “Disrupting power” may be a way of describing this feminist unpicking of power relations into their positive and negative poles.

The book makes a consistent attack on liberal feminism. In one example, Olufemi recounts how the heartrending stories of BAME victims of Ireland’s past total ban on abortion, one impregnated by rape, the other dying as a result of being made to continue with a doomed pregnancy, were used in the successful campaign to amend the Irish constitution to allow abortion, but contemporary living BAME activists who wanted to support the campaign were marginalised as a tactic not to put people off from supporting the amendment. The right to abortion in the south of Ireland has been won, but accessibility is still a problem for poor and marginal women. What we need, even when we must support struggles for abortion rights, is a wider fight for reproductive justice, which addresses deficiencies in access to contraception, and guarantees both income for reproductive labour and availability of child care, addressing problems which are more stark for poor women, especially from BAME, migrant, or other denigrated communities.

Olufemi’s feminism applies to a domestic scale of politics – women faced with poverty and poor housing, with limited opportunities due to racism in the labour market, with close relatives in prison, with domestic violence, with child abuse, with street violence and heavy policing, and so on. Equally, though, it addresses global political concerns about increasing inequality and militarism, conveying an internationalist vision to promote “solidarity as a doing word”, building ‘a strategic coalition of people who are invested in a collective vision for the future’.

An essay in the New Left Review, (Nov/Dec2019) by Michael Hardt and Antonio Negri, called‘“Empire”, twenty years on’ seems to look towards a similar strategic coalition. I had struggled, indeed I think, failed to finish reading ‘Empire’ when I attempted to understand it, probably 20 years ago, but this article starts with a brief recapitulation of its themes along with updating it for the present, a time when, they write, the upsurge of various nationalisms has made the hegemony of the Empire superficially less legible. This article seemed relatively comprehensible – though not exactly on the same level of easy reading as Olufemi.  ‘Empire’ refers not to US military and cultural domination but to an interlocking global extractive system based on various axes of domination, that works through destruction of the commons – privatising public assets and systems, destroying the atmosphere, accumulation by dispossession, and so on – its sovereignty shared between levels which Hardt and Negri characterise as containing monarchical, oligarchical and democratic elements, in a parallel with what was said of the Roman Empire. The Empire includes groups ostensibly oppositional – one example (in the ‘democratic’ tranche!) might be ISIS, born in opposition to US hegemony but actually effectively promoting the global arms industry, Islamophobia, and the new authoritarianism.  Empire feeds on overlapping crises. Hardt and Negri see it as an attempt to contain the threat of a strategic coalition to create globalisation from below: so neoliberal ideology and practice they see as the Empire’s response to the de-colonisation and wave of social liberation of the 1960s. Empire promotes upheaval and fragmentation at every scale from the domestic to the global, always aiming to keep its subjects subjugated.

For Hardt and Negri, the result of this is that the working class is fractured, it can no longer be held up as a unified subject, and its organisational structures, party and unions for example, have been broken; workers are divided by geography in worldwide supply chains, by language and cultural barriers, by racism, gender, precarity of employment, levels of citizenship, entitlements and documentation, and so on. Instead of resistance to capitalism coming from the working class, for the past twenty years, to them, noted opposition has come from manifestations of the ‘multitude’ – such as in Cairo, in Ferguson, in Standing Rock, in Athens or Madrid, but these mobilisations have been short-lived and their gains frequently lost.

What they hope to promote, or perhaps better what they see as emergent, is this ‘multitude’ becoming organised, becoming an ‘intersectional class’. Anticapitalist struggles “must be cast together and on an equal basis with struggles against other axes of domination – feminist, antiracist, decolonial, queer, anti-ablist and others.”…this is where their text began to read like Lola Olufemi’s voice again. These struggles are undertaken with the awareness that no one structure of domination is either primary or reducible to the others, they are relatively autonomous, have equal significance and are mutually constitutive. Indeed they can all be seen as different class systems (they cite Mbembe on race class and Delphy on gender class systems).

Hardt and Negri quote Delphy pointing out that the participants in a gender class system “are not constituted before they are put in relation, their relation is what constitutes them as such.” In other words, ones’ identity is a product of a system of domination, before it is, as it is generally subjectively experienced, either a quasi-natural category, or a way of naming oneself as a member of a certain class along that axis of domination, as a start to organising resistance. This insight, which seems to place a kind of basal, untargetted domination or violence at the genesis of all identities, would, if widely acknowledged, seem to open up the possibility for the sought-after strategic coalition against it. What is needed is not just solidarity in coalition between the groups fighting these different axes of domination, with a merely additive logic, but ‘an internal articulation of these different subjectivities’, to become ‘subjectivities in the key of multiplicity’ leading to an anti-subordination project. This project stems from a shared conviction that you cannot be an anticapitalist without being a feminist, a pro-migrant anti-racist, opposed to transmisogyny, and so on…that is, you are ready always to act in solidarity with the precarious and the dominated and to check and acknowledge your own involvement in negative power systems.
Domination, or bullying, and a politics of resistance to it, does not need any list of human rights; it may be sufficient just to claim for all living creatures the right to breathe, as Mbembe (The Universal Right to Breathe ~ Achille Mbembe, 13 April 2020) puts it. This negative right we should all claim and should all recognise is simply the right not to be abused. Hardt and Negri do refer, in relation to migration, to “the right to escape” – and in the context of the uneven distribution of actually enacted violence this amounts to the same claim.  For them, the people exercising this right and challenging the increasingly militarised Europe border regime, trying to follow the material and financial resources that are being relentlessly drained by extraction from the poorest communities across the globe are themselves, albeit in a scarcely articulated way, actively resisting Empire. The same claim might be made about women seeking to escape from domestic abuse. This seems to be a claim that those who most feel that they have no agency, those who are thought of, too, as desperately lacking resources, are, almost by miracle, important political agents. As it is with the Palestinians in the West Bank and Gaza, disarmed, penned-in, and picked off for murder or torture, mere survival and collective solidarity is resistance. Through stories, music, film, all sorts of cultural exchanges, that resistance can be amplified, acted on across the world, in acts of solidarity articulated with other forms of struggle against other modes of violence. The miracle also requires the recruitment into active solidarity of the witnesses who are not victims. Solidarity as a practice, arises from never contemplating the possibility of addressing the injustices of any one of these systems of violence by mobilising one of the others, introduces a new and challenging kind of politics. It even in a sense overthrows politics as we have known it – a kind of violent trial of strength between different classes – in which the weak will always suffer what they must.

Sarah Hegazi was an Egyptian revolutionary socialist and LGBT rights activist who was imprisoned and tortured for raising a pride flag at a concert in 2017. She moved to Canada where she sought asylum. Away from her family and suffering with PTSD from her time in prison she committed suicide this week. The damage done to people by the perpetrators of domination practices is not just the present restriction that is imposed on their flourishing, there is always the possibility of their having received permanent or at least long-lasting injury, causing a long-term disability, with emotional, mental and physical components. Some of this damage is reflected in the tendency to repeat the trauma, for example by self-damaging practices which provide some relief by reclaiming autonomy. Whilst these practices of self-harm can sometimes be seen as forms of resistance, such as overuse of psychotropic drugs removing you from the labour market, others – venting your fury on those on whom you depend emotionally through domestic violence for example – reveal a process of recruitment into the ‘prevailing systems of violence.’ Not only do some of these injuries to mental well-being thus contribute to the ranks of perpetrators and to the practices and ideology of authoritarianism and militarism, but they also mean that a significant proportion of those who are most entitled to speak, those whose activism most needs to be nurtured, are rendered less able to do so. This is quite apart from their also being deprived of resources – in terms of time, mobility, nutrition, and so on. The abolition of all prevailing systems of violence in this situation becomes a slow, difficult process of working together, and alongside, not something for a vanguard that will be all too ready to substitute itself for the dominated ranks on whichever axis of class.
Those of us who are committed to this ‘overthrow of all prevailing systems of violence’ whose background and income, gender, and sexuality place them in the dominating, violent class and outside the oppressed classes need to listen hard to their voices, and to struggle to avoid contributing to the abuse, to avoid being an agent of its repetition, then to signal support and solidarity – by writing, by attending meetings, by financial contributions to a struggle, by being another body on a picket line or a demonstration, or by whatever means are available to us. Some sort of leadership from this position is conceivable, I suppose – Jeremy Corbyn might be cited as one who makes a good stab at it – but the contradictions and difficulties of such a role seem great. To have social capital is not an unequivocal asset when it comes to a moment of social upheaval. We need collective strength that does not exhaust itself into putting some individuals or any particular party into positions of power within the prevailing structures of violence, but rather pulls those structures down through a constant undermining.
Lola Olufemi says loudly to the relatively privileged women whose oppression presents itself to them only on the axis of patriarchy, that a feminism that struggles for their liberation on that axis alone, and not taken as equal to other axes, obliterates the concerns and needs of other women – of the majority of women – and will fail. Patriarchy, racism and capitalism cannot be fought separately. Care jobs (like those of most of the frontline workers in the present covid-19 lockdown) are badly paid and insecure, and this is related to capitalism’s reliance on unpaid domestic reproductive labour that is ideologically the preserve of women: we should not be fighting for more women to have well-paid jobs in the City of London but for the people who do society’s essential caring work, reproductive labour, to have equal pay and equal status to those financiers, or better to do without those “bullshit jobs” altogether.  Women struggling against their oppression as women have to address the struggles of the most dominated and abused amongst them, and in so doing they will make links with struggles against racial domination, transmisogyny homophobia, ableism, ageism and so on.
What are the practical implications of this politics? After the 2019 election defeat and the leadership change in the Labour Party from Corbyn to Starmer, from a leadership aiming for socialism to one seeking a doomed centrist electoral ’triangulation’ many Labour members are considering whether to go on putting energy into trying to turn the party in to a vehicle for the overthrow of systems of violence; quite a few have already been expelled, joining the many political activists who have never seen Labour as an important arena of struggle.  I think the struggle that Olufemi, Hardt and Negri urge us all to join points us towards plenty of arenas and groups and group activities, some inside but more, probably, outside any one political party.  We are talking about organising a patiently built social revolution which includes the overthrow of the regime of private ownership of wealth and of land that others use; it has to involve the creation of workplace and local democracy, and a regime of global democratic governance.  We need to fight for the closure of prisons, the ending of debt, the disappearance of borders, the end of armies and of weapons of mass destruction, indeed of the whole apparatus of negative domination.

All this presents itself as needing to be done in short order before the planet burns and drowns.   Meanwhile, as global catastrophes follow on one another with increasing frequency, the capacity for the most oppressed to act seems to be in danger of being further diminished by the increasing intensity of their suffering, their displacements and their stigmatisation.  At the same time the wealth of the richest grows, as does their capacity to use their resources to put their agents into positions of state power. We confront massive military power and we cannot resort to counter-domination as a strategy.  However, if we set our clocks at five minutes to midnight, as David Renton warns (The New Authoritarians, 2019, p232) there is a danger some on the left become prey to the allure of quick routes to political success, forming alliances with centrists who offer nothing to the poor and are all too willing to join in stigmatising the dominated – as in voting for Starmer to lead the Labour party.  In fact, across the world authoritarian regimes have flourished in this age of climate catastrophe, as if the world’s natural resources having revealed themselves as limited has stoked the urge to violent claims of property and ownership, and moving the balance of political forces to the right. For the necessary attitude to time ( or to have Hope without optimism as Terry Eagleton puts it (2015)) we have to admit that just as we cannot see at all clearly what a society that will not be structured by violence will look like, we cannot know the extent that it is achievable, or the timescale involved and so we have to take solace in the struggle itself, in the idea that solidarity is its own reward. Resistance to subordination not only aims for health for all, it also expresses and enacts it in the present – it is care, nurture, nourishment. It is worthwhile and necessary in itself, whatever the prospects of future success or failure.

If we can keep a group of articulate insurgents (like Zarah Sultana) within the House of Commons and make it grow, so much the better, so I would urge comrades who are in Labour to stay in, and indeed to recruit others. They should carry on campaigning for mandatory re-selection of parliamentary candidates, all across the country (and particularly in Holborn and St Pancras constituency).
Voters in elections for the UK parliament, as for states elsewhere, are right to recognise that the bourgeois State is there, self-consciously, to foster and maintain the regimes of violence – that is, of the individuals, institutions and groups that control most of the world’s assets through direct violence – from domestic to military – upholding ownership, walls and enclosures, and borders; it cannot be suddenly taken over for another purpose even for one that is obviously more moral and more rational, if the balance of nourishment/violence forces has not already been changed or at least been thrown into serious question.  Voting for social revolution is rightly seen as futile, unless that social revolution is already in progress. We should not blame ignorant voters, but review our tactics and alliances.


We just need to keep on being active, supporting all campaigns of resistance, and we need to recognise one another, striving for that ‘articulation of different subjectivities’ at the same time as not compromising with centrists, neoliberals or liberals. This points to a limit of Corbynism, in that it did not sufficiently emphasise the evident necessity of completely changing the system, which was not surprising as it lacked the strength to argue this even within the Labour Party – the leadership did not want to draw attention to its radical differences from the interests of the establishment.
If the realistic prospects look bleak, then if we look at where the Empire is driving us, it is a frightening place where very few, even the super-rich themselves, will want to go – wealth concentrated in fewer and fewer hands, environmental catastrophe, hunger, disease, warfare, chaos and suffering on an unprecedented scale involving not just humankind but all species. Purely on the level of economics, the impoverishment and over-indebtedness of the vast majority of the population is not compatible with economic growth, and extraction of the remaining small pockets of wealth in the middle classes, through rents and fees, is draining a finite reserve.
The Covid-19 pandemic, on top of the accelerating disasters attributable to climate change shows us, as Tithi Bhattacharya and Gareth Dale argue in ‘Covid Capitalism’, that “the accumulated economic pasts of capitalism and its cumulative depredation of nature have etched their indelible marks on the system…rescuing this system through reform is no longer an ambitious hope or the subject of an interesting intra-left debate, but a dangerous fantasy.”

To put it differently, the pandemic shows us that we do need governments (not just or not necessarily of nation-states but at all sizes of territory) that are democratically accountable as institutional actors whose power lies in their capacity to mobilise resources to enable society collectively to provide care and protection for all within each territory.  Such effective government has been found severely wanting in the UK, even more notably than elsewhere, but the fact that political action has had to manifest itself as an exercise in care is already a significant change, a brief moment of insight, to which the UK government has had to adapt, through the reluctant temporary exercise of many of Labour’s supposedly wildly expensive economically and socially unacceptable policies, that they and their billionaire-owned press and corporate funders had demonised before the electorate only a few weeks before. They will try to go back to asserting that ‘there is no alternative’ to a regime of negative power, but we have a chance to demand that a regime of care, fostering public health, remains in sight and grows, as we all have glimpsed its necessity and its possibility.

NICE guidance and the necropolitics of Covid-19.



NICE guideline [NG165].  The necropolitics of Covid-19 in England.

The government has been forced by the Covid-19 crisis to address the health of the public, but has done so through gritted teeth, spectacularly incompetently, and with its sights set doggedly on employing their friends and sponsors in private multinational corporations.  Having done nothing to stop people with Covid-19 coming into the country, Johnson delayed the lockdown for as long as possible – a lockdown one week earlier would have saved 30,000 lives. (1) Decades of neoliberal policies have destroyed and fragmented  the infrastructure that previously existed for providing public health services in a crisis.(2). 

In February of this year, after long exposure to ideologically-driven depredations – fragmentation, commodification, outsourcing, privatisation, financialisation, bureaucratisation – the NHS and social care systems in England were in a parlous state.  Though these were less publicised than in the previous winter, there were again queues of ambulances waiting to get acutely ill people into A&E departments, again people waiting for hours on trolleys and dangerously high levels of bed occupancy combined with severe understaffing.

Yet shortly after the peak of the first Covid-19 wave in April, Simon Stevens  – one of those chiefly responsible for the ruination of the NHS in England – reported,    “Last week emergency hospital admissions were at 63% of their level in the same week last year.”  (3)   At the same time, thousands of people – about a third of all the deaths from Covid-19 – most of them aged over 65, were dying of Covid-19 pneumonia in their own homes or in care homes up and down the country, looked after by family members, by visiting care workers, or by employed care home staff, most of whom lacked nursing training, had little or no access to oxygen or to palliative care drugs, and had inadequate PPE.(4)  Thousands who might have been receiving a diagnosis even, or an adequate appraisal of the severity of their illness, and professional nursing care, adequate oxygen supply and monitoring, physiotherapy, or, if their condition worsened, expert palliative care, were denied all these things.  Austerity has been well described by Ruth Wilson Gilmore as institutionalised abandonment. (5).  Here we have a clear example of its practice on an unprecedented scale in terms of the harvest of deaths without adequate medical and nursing care that it facilitated.

By the term ‘necropolitics’ Achille Mbembe  refers to the state, or its agents, exposing people to death or to social death, as a matter of policy, within the territories it controls (6). What follows is a provisional attempt to investigate how this intrusion of necropolitics into the health care system was achieved through professional guidance issued to GPs.

The National Institute of Clinical Excellence, (NICE) is an executive non-departmental public body of the Department of Health in England.  NICE is widely respected by NHS staff and has generally functioned hitherto as a protective mechanism for the NHS from the exorbitant demands of the big pharmaceutical companies.  It is a means, through its issuing of clinical guidelines, to try to ensure that health care professionals across the country work to constantly updated evidence-based standards.

NICE guidance, directed at primary care doctors, or their surrogates such as nurse practitioners or NHS 111 staff, called “COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community, NICE guideline [NG165]”  was published on 3rd April 2020 (7). There are likely many other relevant documents, such as local guidance issued at different NHS England levels – integrated care partnerships, or clinical commissioning groups, for example – and by professional bodies such as the British Geriatric Society,(8) which may have been effective in much the same direction.   Directions and nudges were doubtless conveyed via other media than written guidance documents.   Yet this NICE guidance is both central to and illustrative of the process that unfolded.

The document opens with a reassuring preamble, albeit in small print,

The guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.”   

It goes on..

“The purpose of this guideline is to ensure the best treatment for adults with suspected or confirmed pneumonia in the community during the COVID-19 pandemic and best use of NHS resources. We have withdrawn our guideline on diagnosing and managing pneumonia in adults until further notice.”  (My emphasis)

No further reason or argument is given for this withdrawal, and most importantly nothing is put in its place.  As nudge theory has it, readers offered such a void are likely to adopt the default option, they are in effect being nudged towards doing nothing. 

The guidance continues:

“2.1 When possible, discuss the risks, benefits and likely outcomes of treatment options with patients with COVID‑19, and their families and carers. This will help them make informed decisions about their treatment goals and wishes, including treatment escalation plans where appropriate.

2.2. Find out if patients have advance care plans or advance decisions to refuse treatment, including ‘do not attempt cardiopulmonary resuscitation’ decisions.


4.1.  Be aware that older people, or those with co-morbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions, are more likely to develop severe pneumonia. Because this can lead to respiratory failure and death, hospital admission would have been the usual recommendation for these people before the COVID‑19 pandemic.  (my emphasis)…(and note there is no replacement recommendation.)

4.2  When making decisions about hospital admission, take into account:  the severity of the pneumonia, including symptoms and signs of more severe illness…. the benefits, risks and disadvantages of hospital admission…. the care that can be offered in hospital compared with at home….the patient’s wishes and care plans….service delivery issues and local NHS resources during the COVID‑19 pandemic.

4.3  Explain that:  the benefits of hospital admission include improved diagnostic tests (chest X-ray, microbiological tests and blood tests) and respiratory support….the risks and disadvantages of hospital admission include spreading or catching COVID‑19 and loss of contact with families.”

The guidance notably fails to make any distinction between clinical assessment and decisions about treatment, which in any effective medical consultation are quite different phases.  Often, because of lack of full PPE in the community, the doctor (or their surrogate) during this epidemic will have been consulting remotely using a telephone or a video link.  They can still gather a history of the illness, though even this may be impaired by lack of hearing, by a poor connection, by the person having been alone and now sick, or by the absence of an interpreter, but effective examination is minimal.  This limited capacity to provide any but an inadequate and provisional examination might reasonably be expected to lead to more emphasis being placed on the results of investigations – pulse oximetry to ascertain the level of oxygen in the blood, swabs of the nose and throat to look for Covid-19, blood tests (to look for anaemia, evidence of bacterial infection, bad diabetic control, or kidney problems), chest x-rays or a CT scan of the chest.  It is after such an assessment, when the patient has maximised their knowledge about what is wrong with them, that the consultation or a series of consultations should go on to offer alternatives as to the nature and the site of their further care, leading up to the patient making a choice.   These are basic sequences and well known features of adequate consultation practice, literally the basics of training in primary health care.  How can a frightened and sick elderly person be asked to make a decision about their care, aided by their families if present, when they have not been given access to the necessary information to make it?  The fear of separation, removal from known surroundings, and of a lonely death looked after by masked strangers, can readily be used to tilt the scales towards a decision to stay at home to face death or recovery without any NHS support, without them being able to notice or protest that key phases of an adequate consultation have been missed out. 

Most of us are familiar with situations, after an accident or an acute illness, when we have to go to a designated place, usually an A&E department, to have an assessment, because x-rays or some other technology or expertise are required; after that, we can decide, or can be advised, to go home for the rest of the treatment.  There is absolutely no reason why Covid-19 infection should have been any different – everybody who was significantly unwell, and the elderly disabled in particular, needed to have access to proper assessment before they could consider where the rest of their care was to take place.  Moreover, those who decided to go home after such an assessment could at that point have been given PPE for their carers, to prevent further spread of the infection to them.

Quite a few people over the age of 65 have made Advanced Care Plans, after discussion with their GP, with the purpose of trying to ensure that they will not be subjected to futile or excessive treatment in the future, should they be in a situation where they have a terminal illness.   Others will have signed ACPs at the time when they learn that they have such a terminal illness, following a sufficiently exhaustive series of investigations.  Terminal illness here can mean incurable cancer, but it may also mean severe chronic lung disease, neurodegenerative disorders, or heart failure, for example.  The basic assumption made about the occasion on which an Advanced Care Plan will become operative, is that the information available to the person concerned – or if they lack capacity, to their relatives – has been optimised on the occasion when it is brought into operation.   To refer to ACPs in the same clause as ‘refusal of treatment’ is an iniquitous confounding. 

Yet during March and April primary care teams were being encouraged to work towards signing up as many as possible of their disabled population over 65 years old to ACPs, which were to be taken as consent to the withdrawal of adequate assessment or any kind of hospital care, should they be suspected of contracting Covid-19.  

The City and Hackney set of instructions to GPs based on these NICE guidelines and the British Geriatric Society guidelines on Covid-19 in care homes, a local bulletin issued by City and Hackney CCG on 1st May, urged them to get yet more ACPs signed (11).  This went beyond reminding doctors of the the generally accepted and evidence-based notion that mechanical ventilation in people with a moderate level of frailty is futile, by suggesting that doctors should advise all moderately frail patients over 65 years old – those who have problems with stairs, need help with bathing, and need help with outdoor activities – that admission to hospital for any reason would be futile, and suggesting that they should sign up in advance that they would prefer to have care at home.  A previous City and Hackney document issued on 20th April (12) had  also asked GPs to consider that those with even just mild frailty – those who are rather slow and need help with such things as their finances, transportation, medication or heavy housework – should be encouraged to opt for ‘home treatment’ where possible, if they were later suspected of Covid-19 infection.

Reports emerging during March which suggested that batches of patients were being signed up for ACPs without any individualised discussions led to the publication of a joint statement from the British Medical Association (BMA) Care Provider Alliance (CPA)  Care Quality Commission (CQC)  Royal College of General Practice (RCGP) on 1st April to stop this abusive practice (9), but the statement did not address the mis-use of pre-existing plans, nor address the confusion between assessment and treatment, or between treatments that would be futile and other treatments that might be needed.  Many who had already expressed the wish to die at home from their diagnosed conditions or from future terminal conditions long before Covid-19 had emerged, were also to be deemed, it seems, to have made the same decision in relation to this acute infection.  This was a bureaucratic procedure facilitating an unethical interpretation of what advanced care planning means. People who signed an ACP in good faith, not in order to refuse assessment of their condition, but in order to avoid being subjected to futile treatment, had this ACP used to shut them off from any adequate assessment and from accessing other treatment, palliative or otherwise, that would be far from futile.

Those who could most clearly articulate their rights and their reasonable expectations of a functioning health service, or whose relatives or friends were there to advocate for them, would have been the ones who overcame these barriers and were sent to the hospital to be assessed.  This is an example of what the late Julian Tudor-Hart in 1971 identified as the inverse care law, “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”(10). Using a second language,  existing disabilities of hearing, sight or cognition, and the weight of a lifetime of experiences of domination and abusive practices, all obviously militate against standing up for ones’ autonomy in these deliberations about whether you should be given care, especially when those discussions deliberately conflate assessment and treatment, and are unclear or even blatantly wrong  about which kinds of treatment might be futile.  This is guidance designed to limit access to care for the disabled and for the underprivileged, and may be one of many pathways that has led to the preponderance of BAME deaths observed during the epidemic. 

Many doctors working in primary care across England will not have altered their practice at all because of this withdrawal of the guidance on treatment of pneumonia, because they use guidelines that give them useful information in responding ethically to the needs of the patient in front of them, and disregard those that fail in this respect.  Likewise, many disabled people who called for emergency help, suspecting they had Covid-19, may have  been able to insist on their need for a proper diagnosis and for better care than they could receive at home or in their care home.  Many asked to sign up to ACDs in the weeks before the pandemic struck will have realised that it was not in their interest to do so.  

Moreover the outcome at the height of the first wave of Covid-19 in England, seen in terms of the capacity of hospital services being under-utilised at a time when there were many dying of Covid-19 in the community, and particularly in care homes, may well have had more to do with the government’s reckless decision to order hospitals to discharge large numbers of elderly patients into care homes, thus greatly increasing the number of people likely to be infected by them.  But the NICE guidance was pushing in the same direction – that is, creating a group that could and should be sacrificed for the greater good.  If fashioning such a Pharmakon is a proper function of the state, then a critique of the moral basis of such a state is in order.  Certainly it is not a function of a health service, which is meant to be the workplace of professionals, whether nurses, doctors, or others, who are meant to act with quite different ethical imperatives.

Boris Johnson and Matt Hancock have congratulated themselves that the NHS did not actually collapse in the face of the massive first wave of Covid-19 infections that they had allowed to happen.  It is a bitter irony that NHS England, having been fragmented and commodified  by a coterie of enthusiasts for US health care systems, such as Stevens, has resulted in its reaching a condition in which the accusations levelled at NICE and at the NHS by US cheerleaders for private health care – that they represent not just a systematic restriction of the free market, but a denial of the dignity and rights of service users – can at last seem to have some truth in them.  Advanced Care Directives have been tarnished (13).  From now they should carry a health warning: “This directive could seriously damage your health, as it can be interpreted as an invitation to institutionalised abandonment.”




 (1)  Front. Public Health, 29 May 2020 | COVID-19 UK Lockdown Forecasts and R0. Greg Dropkin,  Independent Researcher, Liverpool, United Kingdom

 (2) Guardian,  31st May, 2020, Felicity Lawrence, Juliette Garside, David Pegg, David Conn, Severin Carrell and Harry Davies.  “How a decade of privatisation and cuts exposed England to coronavirus.”

(3) Letter from Chief Executive Sir Simon Stevens & Chief Operating Officer Amanda Pritchard

to Chief executives of all NHS trusts and foundation trusts, CCG Accountable Officers,

GP practices and Primary Care Networks, Providers of community health services,  NHS 111 providers, 29 April 2020.

4)  Office for National Statistics, Statistical bulletin 

Deaths registered weekly in England and Wales, provisional: week ending 22 May 2020 

Provisional counts of the number of deaths registered in England and Wales, including deaths involving the coronavirus (COVID-19), by age, sex and region, in the latest weeks for which data are available.  2nd June, 2020

“The year-to-date analysis shows that, of deaths involving the coronavirus (COVID-19) up to Week 21 (week ending 22 May 2020), 64.2% (28,159 deaths) occurred in hospital, with the remainder occurring in care homes (12,739 deaths), private homes (1,991 deaths), hospices (582 deaths), other communal establishments (197 deaths), and elsewhere (169 deaths).“

(5). Ruth Wilson Gilmore on Covid-19, Decarceration, and Abolition. Webinar by Haymarket Books 17 April 2020

(6) Mbembe, Achille (2003). “Necropolitics”. Duke University Press, 2011.

(7) COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community

NICE guideline [NG165] Published date: 03 April 2020 Last updated: 23 April 2020

(8) COVID-19: Managing the COVID-19 pandemic in care homes for older people

Good Practice Guide. British Geriatrics Society 30 March 2020

(9)  British Medical Association (BMA) Care Provider Alliance (CPA)  Care Quality Commission (CQC)  Royal College of General Practice (RCGP) 1st April 2020 A joint statement on advance care planning –

“The importance of having a personalised care plan in place, especially for older people, people who are frail or have other serious conditions has never been more important than it is now during the Covid 19 Pandemic.

Where a person has capacity, as defined by the Mental Capacity Act, this advance care plan should always be discussed with them directly. Where a person lacks the capacity to engage with this process then it is reasonable to produce such a plan following best interest guidelines with the involvement of family members or other appropriate individuals.

Such advance care plans may result in the consideration and completion of a Do Not Attempt Resuscitation (DNAR) or ReSPECT form. It remains essential that these decisions are made on an individual basis. The General Practitioner continues to have a central role in the consideration, completion and signing of DNAR forms for people in community settings.

It is unacceptable for advance care plans, with or without DNAR form completion to be applied to groups of people of any description. These decisions must continue to be made on an individual basis according to need.”

(10) Tudor Hart, J. (1971). “The Inverse Care Law”. The Lancet. 297: 405–412. doi:10.1016/S0140-6736(71)92410-X. PMID 4100731.

(11) City and Hackney CCG Bulletin for GPs, issued 1st May 2020, section on Advanced Care Planning.

(12) COVID-19 primary care guide to decision making around escalation priorities, advance care planning, palliation and end of life ,16th April 2020 

The aim of this is a guide is to support GPs with advance care planning prior to COVID-19 infection. It also considers when to convey to hospital those patients who do not have a Coordinate My Care (CMC) plan in place but have a history that put then in the high-risk group with a degree of frailty.  City and Hackney CCG, Homerton University Hospital Foundation Trust, and City and Hackney GP Confederation.

   (13) British Geriatric Society.  Did the UK response to the COVID-19 pandemic fail frail older people? 14th May 2020. Rowan H Harwood


This  document which I am going to start by reproducing in full, was issued by the Clinical Commissioning Group in Hackney, last week.  Hackney has seen the third highest number of Covid-19 deaths of any borough:




“City and Hackney CCG Bulletin for GPs, issued 1st May 2020, 

 Advanced Care Planning.

ACPs (Advanced Care Plans) are part of a discussion with frail groups of patients and animportant opportunity for them to decide about what and where they wishto have treatment as well as a discussion around what treatments they would want to avoid.

A recent audit showed that we have 999 (25%) CMC (Co-ordinate my Care) records where a decision has not yet been made around escalation.

A number of these are likely to be because the patient is uncomfortable or unable due to mental capacity to make the decision.

However, where possible it would be in everyone’s interest to support and encourage patients to indicate their preference, especially in light of the Covid 19 pandemic.

Building on the work you have already put into updating your CMC’s we wanted to offer support and clarification on which groups of patients should be prioritised as you continue to support your patients.

Focus should be placed on ensuring the following groups of patients have up to date care plans:

Patients in care homes and supported living facilities;

Those on the End of Life Care and Proactive Care registers;

Those that are due for review as per the review date set by the GP.

As always, it is important to ensure that patient’s preference for place of care and death are discussed and captured within the plans. During the Covid 19 pandemic, it would also be helpful for LAS and ED if you are able to include the suggested script for patients who have:

Identified preferred place of care as home and uncertain about preferred place of death or  Indicated wanting home or hospice for preferred place of death

a CFS 6 and greater but wishes to have their care escalated.

Suggested Script: In the Coronavirus Pandemic this patient would be likely to have a poor outcome with COVID 19 infection and would not be considered for escalation for ventilation in hospital, as they would be unlikely to survive if they became seriously ill hence will benefit fromsymptom control and care at home.

The priority during the COVID pandemic is to give patients the opportunity to decide, based on lack of benefit with hospital admission amongst patients with CFS6 (Clinical  Frailty Scale) or greater, whether they would prefer to have care at home.

There will be those, for whom you appreciate the lack of benefit in admission (CFS 6 and greater) but who wish to have their care escalated. For this cohort of patients please put for resuscitation and escalation and add the suggested script, which will assist the EDand LAS in these discussions and assist the decision-making in the ED.

What support is available?

If practices require help identifying patients within the groups listed above we will be distributing ‘how to’ guides and running a webinar for practice administrators. Please encourage your practice administrators to attend if this is an area of concern for you. We will also be sending out an excerpt of data that we have received from CMC listing all your published and unpublished CMC’s which may also be of help. We also havea small team of geriatricians at the Homerton who are able to support with completing a number of CMC’s if there are capacity issues within the practice.”


This bulletin was sent to all primary care staff and institutions in City and Hackney on 1st May, 2020;  I have changed one sentence to italics, and added the meanings of  abbreviations used in brackets.



At a time when there is a continuing high death toll from Covid-19 of people in care homes, when hospital wards are relatively empty and indeed the ExCel centre facility has been mothballed for lack of use, I am concerned about the grave errors in this document.  It instructs GPs and their teams to accelerate the process of getting people in the community who have moderately impaired mobility (for example, difficulty climbing stairs) – that is, Frailty score grade 6 or above – to agree to Advanced Care Plans – a reasonable, if rather bureaucratic ambition, and not one that one would hope busy GPs should be spending time on during a pandemic.  Such care plans, the document explicitly instructs, are to be used to encourage frail people, if they are suffering from Covid-19, to agree to being looked after at home.  The case for this is argued on the basis of evidence, which I do not dispute, that such frail people will not benefit from mechanical ventilation.  However, being admitted to hospital where you can have your oxygen saturation regularly checked,  can be given oxygen if necessary,  can be nursed by trained professionals, can have physiotherapy, can have antibiotics and other drugs, and can access numerous other benefits, is not at all the same stage in the process of care as when your condition has further deteriorated, when you and the team looking after you are faced with the question of your being mechanically ventilated or not.  

Moreover, in hospital you will be looked after by staff who have relatively greater access to PPE and are trained to use it, whereas in the community you may continue to spread the disease, with any carers you have access to being ill-equipped to avoid becoming vectors of the infection, passing it to yet more frail people.  Finally, of course, assessment in the hospital setting does not necessarily mean admission to hospital, it just means that the decision as to whether hospital care would be beneficial is guided by much stronger evidence, such as a chest x-ray, arterial oxygen levels, CT scan of chest, a Covid-19 antigen test, or whatever else is deemed necessary to improve that decision.  The effect of the CCG’s instruction is to deny patients that quality of assessment, which cannot be provided in the community.  Such assessment is MORE important if you are frail, not less, because the presence of other chronic conditions – chronic lung disease, or cardiovascular disease, for example – makes the clinical assessment more difficult.

I myself, if asked to make an Advanced Care Plan, would definitely opt for dying at home rather than dying in hospital.   This has absolutely zero relevance as to decisions, if I am stricken with Covid-19, about which clinical setting will provide me with optimal care, or even which setting I would prefer.  As far as we know, anyone with even quite severe Covid-19 infections can still hope to recover fully, however bad their underlying health – it is only when they are critically ill with the infection that those with serious underlying conditions, including moderate frailty, have to resign themselves to the likelihood of death. To use a person’s Advanced Care Plan as a guide to action as to how to treat them in the middle of a pandemic, in the community, where  the severity of that person’s infection is hard to judge, being made without any tests or investigations, is a travesty which anyone would be hard pressed to deny has eugenicist connotations.

The paper’s assertion that there is a “lack of benefit with hospital admission amongst patients with CFS6 or greater” is a barefaced inaccuracy amounting to a falsehood.

This confused and possibly wilfully wrong message will have tended to make its readers hesitate to send people to hospital even when they would actually benefit from hospital care.  It seems to be aimed at inducing what might be referred to as herd behaviour on the part of doctors in the community, giving them a get-out clause from the paramount ethical obligation to consider the needs of the person whom they are treating, consideration which of course always necessarily, when it comes to taking action to meet those needs, has to take account of what resources are available.  It seems possible that this advice may already have cost the lives of many of the most vulnerable of Hackney’s citizens, particularly those whose frailty is compounded by other disadvantages – being black or brown, being poor, being socially isolated and without articulate mentors and so on.  I would very much like to know whether it is based on instructions from NHS England, or whether it is a purely local mistake.  I am gravely concerned about local GPs and other staff over which the CCG has governance being unwittingly recruited to what amounts to a eugenic practice, in the face of the difficulties of the NHS gatekeeping role and their concern to protect hospital colleagues from being overwhelmed by demand. 

I have written to the CCG to ask them to rescind this incorrect advice immediately, and to be fully transparent about any instructions from higher levels within the Inner North East London ‘footprint’, the Department of Health, or NHS England from which it will have emanated.  In view of the seriousness of the matter, and its continued relevance to the fate of those infected with Covid-19 in Hackney, I want an urgent reply.  Clearly this is a matter of acute and urgent public interest.

On filling in the Census Rehearsal.



The trial run of the 2021 national Census asks the Census-filler to consider the “National Identity” of each member of the household, even offering some suggestions, such as “British”, “English”, “Welsh”, “Scottish”,  “Irish”, or “Other”.

I filled it in for myself as “Other – unresolved”.   The ‘unresolved’ was at first just a reference to the present political situation, with the threatened demise of the UK as an entity, but on further reflection this response suited me at a deeper level.  I wanted to hint at the possibility that we all might come to consider our identity, or rather identities, not as something dictated to us by the nightmare of history, but something orientated towards the future.  

I began that section of the questionnaire with a simple rejection of the alternatives on offer.  It is hardly timely to call one’s national identity “British” at a time when the Prime Minister is actively trying to render a “British” national identity a historical curiosity, pursuing policies which make the break-up of that always artificial and provisional ‘nation’ likely.   Anyway the word ‘British’ still conjures up the crimes of Empire…not just the massacres, and the wars, the slavery, the settler-colonialism and genocides, but the very invention of race; and these crimes are not all in the past, they still are being carried out by the afterlife of Empire – by the City of London as a hub with its tax-evasion spokes, by the mining conglomerates with their bases in London, and by all the other multinational networks of domination and extraction, even if they now have to shelter behind US military violence as much as behind the UK’s own military force.  

In any case decades of mobilising against thugs and bullies with their Union Jacks and their crosses of St George have been enough to sour my willingness to claim to be either British, or English.  I disavow any association with those categories.  I strongly oppose all Nationalisms as political creeds, so why do I have to espouse a ‘national identity’ at all?  I might until recently reluctantly admit to being European, but even that as something to be proud of, to cherish as an avowed identity, seems out of reach now, tainted as it is by deliberately stoked-up mass xenophobia and by the bodies of thousands of drowned refugees.

I had similar difficulty with other parts of the questionnaire. Was I white, black, or mixed?  I put down “Other – vitiligo” – referring to the skin disease which makes me multicoloured in patches large and small all over my face and body – a mixture of very white and slightly brown.  This was an evasion, I know – my actual skin colouring wasn’t the issue: I just did not want to own up to the shameful category of being ‘White’… a member of the group that invented race in order to be able to ascribe it to the dominated and abused Other: a group chosen, not by God, but by the successful deployment of violence.  I oppose racism, though I will own up to displaying it sometimes despite my efforts.  But I also oppose race altogether, as an abomination, a false categorisation of people that arises from the impulse of imperialism to steal land, and to enclose it, to be worked then by the slaves or the wage-slaves that have been driven out of it.

The Census questionnaire did not give any guidance on the terms ‘Sex’ and ‘Gender’ , it asked about both without clarifying the meaning of either word as they wanted to use them, as if they were not contested or problematic terms.  Anatomy, assumed chromosomes and, I admit, a long-standing sense of what I am, prompted me to confess to Sex – “male”, but I really did not feel that I could sign up to belonging to the male gender, with its assumption and regular exercise of patriarchal power, which is just as much the product of violence as “British” or “White” is the product of Empire.  I put myself down as  gender “Other — unresolved” for a second time.

The section on sexuality was voluntary, but having warmed to the category I had invented, rather than leaving it blank, I again wrote “Other – unresolved”.   This conveys a hint of an uncertain, exciting, and multi-layered future to which I might aspire.  Having a sexual orientation, at least to some extent or at some stages of life, does, after all, precede sexual experience.  Sexuality is inherently related to dreams and fantasies, and so it is to some extent inherently future-orientated. 

The whole exercise confronted me with the fact that I am the holder of unspeakable identities that I cannot easily disavow, and which I know other people who know me must ascribe to me – white, male, heterosexual, middle-class, well-off, British.  They are all categories tainted with violence, categories defined by ongoing exclusion and domination.  Should I be made to confess to such belonging?  Yes, perhaps I should, and let the felt shame lead to silence, so that other voices can be heard, all the voices that have been silenced by violence and exclusion; I hope I do go along with that injunction a lot of the time … that my silences in meetings and social groups can thus have an honourable justification, not just be ascribable to social disabilities.  However, I cannot resist the impulse to dissociate myself from all those categories and to declare myself as something other, something not with a basis in the past, but in the aspired-to future – such as a believer in material equality, an internationalist, a communist, someone for gender equality and fluidity, an extinction rebel, and so on… and thus entitled to speak.  This is why the Census seemed like a challenge.

My evasive and even misleading answers will be taken as sabotaging the efforts of the Office for National Statistics to provide researchers with accurate data about the population that is needed for the government to take actions to protect disadvantaged groups.  This argument sounds rather hollow, though, when we have a government that is actively promoting social inequality and disadvantage, a government that wants to encourage people to espouse a certain “national identity” that will recruit them to the ranks of xenophobia and discrimination.  We have a State that will be more likely to use figures about the proportion of people who are not “White” or not “British” to prove that ‘we’ are being over-run with “swarms” of foreigners.  We have had such a government for a decade or longer, and very obviously since 2014 when Theresa May crafted the ‘hostile environment’ strategy.  

The problem is deeper than that, however: the Census questions urging citizens to categorise themselves into sets, albeit with the escape set of “other”, are themselves products and expressions of a particular ideology, generally accepting of patriarchy, empire, and grossly unequal ownership of property, and their resulting hierarchies, fundamentally accepting of the very inequalities which it ostensibly aims to measure so as to reduce or modify them.  This acceptance goes along with the fundamental liberal Enlightenment acceptance of the right to own Property – and I mean by Property more than the property – land, food, shelter, smart phone or whatever that is essential for ones’ own use.   This unrestricted right to Own – the outcome of 1789, along with other liberties – means above all the right to exclude, the right to dominate.  It means that society has to be structured as a regime of violence, even if that violence is not being acted out all the time.  Walls and borders, contracts and trade agreements are all means of hanging on the benefits of overt violence, which has to be there in the background and indeed has to be seen and used from time to time in case people start to forget what is the real basis of society, or indeed of the global order as a whole.  This system of structures includes the structures in our minds that we might call our identity.  The Census assumes and in its modest way reinforces this ideology – it asks, “where do you place yourself in this structure?”- this structure of domination – as if it is timeless and immutable and cannot be demolished.  As if the urgent task before us was not to knock it down, which would mean moving out of all our sets, including moving forward out of the sets of the oppressed which people now can understandably be proud to be in.  

 If you object to “race” as a disgusting fiction born out of the violence of imperialism,  can you classify yourself racially?  If you stand against all forms of nationalism, should you be forced to own up to having a “national identity’?  If you detest patriarchy, do you have to confess to being male?  To all these questions I say, “no”.  For those like me without a dominated set to belong to, selecting  “Other”, as the set to which they belong could be seen as a gesture of solidarity with the excluded and the exploited Other whose existence alone gives meaning to all the sets of dominator identities and categories on offer.  This “Other” is  a self-identification available to all those who do not belong to all the really Othered categories, but who are “always with the Oppressed, never with the Oppressor.”   That means being always with the Other.

When enough of us have embraced being “Other” we will have moved forward, perhaps, to a better society in which the future existence of our planet may once again seem possible.

Abu Dis – the Separation Wall – a sculpture of our times.

via Abu Dis – the Separation Wall – a sculpture of our times.

Abu Dis – the Separation Wall – a sculpture of our times.

    The Separation Wall in Palestine:

1).   As a physical presence:



For a visit to Palestine in April, organised by Camden Abu Dis Friendship Association, we were based in Abu Dis, once an outlying suburb of Jerusalem, now itself divided by the Wall and the main part cut off from Jerusalem by the Wall, and thus cut off from basic services such as hospitals, educational institutions and cultural centres.  Thus it is a really appropriate place to see the Separation Wall and to appreciate its effects.

IMG_4850The Separation wall in Abu Dis from the viewpoint of a demolished house. Beyond the wall, on the horizon – near to the protection of the Israeli army camp that is this side the wall under the radio mast and dominating Abu Dis – is a US settler’s house near the Wall.  In what was once a  farm house – the white building in a clump of small trees – an Arab  family manages without water and electricity, but so far prevents by their presence and ownership of the land the planned building of a planned much larger Israeli settlement.



2 To get into East Jerusalem from Abu Dis took us about an hour and a half, including half an hour or so waiting at a checkpoint which was like an airport security system but much darker, more dirty, and more intimidating.  It used to take 20 minutes, and it still does take that time for the settlers who live in the sprawling settlement of Ma’ale Adumim, which is actually further to the east.


IMG_5150Looking back through the checkpoint for pedestrians between Abu Dis and East Jerusalem.

Huge height of the wall in the towns is like a prison wall, totally blocking out the people and the scene on the other side, so that their oppression and immiseration is out of sight and out of mind, and at the same time it is an extension of imprisonment into the West Bank communities  


Wall cutting across Abu Dis


The main road of the town is blocked by the Wall in the town at the Jerusalem end and you have to turn down a side street.

2). The Wall, settlements, and militarism as an integrated system of domination:

The Apartheid Wall extends for 810 km and cost $1.3 billion.    Far from tracing a route, like Offa’s dyke or Hadrian’s wall, to enhance the defensive possibilities of a border, the Wall meanders to capture the best land, and to create a system of security for numerous settlements, which are located throughout the West Bank in the areas that are under Israeli military control.   Indeed the settlements, and the fences that surround them, and the settlers roaming the countryside with their automatic weapons,  the drones that carry out surveillance overhead, the watchtowers, and the vast array of weaponry that is at the disposal of the Israeli army can really be seen as parts of the same system.

As we travelled to Ramallah, to Jericho, to Bethlehem and to Hebron, we sometimes lost sight of the huge scar across the landscape made by the Wall,



The Separation Wall to the East of East Jerusalem.                    


…….  but we scarcely ever lost sight of the settlements, which are deliberately placed strategically on high ground to dominate the landscape and thus to express entitlement to the landscape as a whole. 


We visited three Bedouin villages where people live who have already been displaced northwards from the Negev area in 1948 and subsequently after 1967 they have had their freedom to move around progressively curtailed, though they still try to cling to their way of life that involves grazing animals on open land.  These villages have been thrust into the forefront of the struggle against the encirclement of East Jerusalem with a ring of settlements; though they are on land which actually belongs to the wealthier inhabitants of nearby towns such as Abu Dis, it is land designated as under Israeli military control, so they have been subjected to frequent demolition of their homes, and their schools, destruction of their wells, with prevention of adequate road access and deprivation of electricity.

IMG_5130Al Khan al Ahmar school – still standing after last year’s desperate campaign and international outcry, but still under threat of demolition.

IMG_5120 (1)Jabel Al Baba view over to settlement.



Settlement of Ma’ale Adumim seen from many-times demolished Bedouin village of Jabal al-Baba



IMG_2725 2 (1)Settlement over Wadi Abu Hindi village, from which diverted sewage has been poured at times, and – when a marquee was set up for a wedding – burning tyres.


The settlements have access restricted to Israelis except for Arab workers with special short-term passes, and they have their own interconnecting roads and routes to Jerusalem that non-Israeli vehicles cannot use.  Where such an Israeli-only road meets a main road connecting West Bank cities, the settler road always seemed to have priority, so that the Palestinians had to queue again and again to give way according to a racial logic of inferiority. 


IMG_4935Picture of array of passes from Walled-Off hotel exhibition

70% of the land area of the West Bank is controlled fully by the Israeli army, so that the cities and towns where there is nominally Palestinian control are like isolated enclaves, surrounded by some villages where there is nominally joint control, in a kind of no-man’s land that is also subjected by Israeli military incursions and surveillance, and itself surrounded by hostile settlements.

We came closest to an Israeli settlement  beside the small enclaves of mostly American extremist settlers in the middle of Hebron, where there are almost daily settler attacks on the indigenous population, with army house searches, arrests and tear gas. 


Steps lead up to a house broken into that morning in Hebron. 


IMG_5357 (1)Children going through a gate in Hebron into the guarded settlement area where some Palestinian Arabs still have their homes, here a child was killed last year who did not understand instructions shouted in Hebrew.

IMG_2812 2Young woman hand on gate in Hebron.

IMG_2811 2 (1)Hebron access gate in the ruined market area near Shuhada Street.

East Jerusalem:

 The system includes the isolation, with their limited and separate citizenship, of the Arab population of East Jerusalem who in the effort to constantly increase the Jewish proportion of the city’s population are subjected to severe restrictions as to marriage, obstruction of relationships with people from the West Bank, travel restrictions, and difficulty and legal expenses trying to register the existence of their children  so they can get schooling and health care.  They face the constant threat of confiscation of their homes, with expensive litigation the only uncertain route to getting their home back once they have been evicted by settlers.  Others who have built or extended their homes without the building permits that are impossible for Arab applicants to obtain, face the constant threat of their home being demolished, or even of being forced to demolish their own homes rather than having to pay  the inflated costs imposed when the Israeli army do it.  Where homes are taken over, the militant settlers who occupy them regularly throw acids, rocks, or excrement down at their neighbours.

IMG_5192Courtyard with objects on the roof picture

IMG_5191 (1)Doorway into shared courtyard where a child’s arm was burned with acid thrown by a settler youth living above.


IMG_2751Israeli flags on house in Via Dolorosa in the heart of the Arab quarter of the Old City

IMG_4941 (1)House demolitions  – Walled-Off exhibit photo – if you had thirty minutes before your home was demolished, what would you save?


 The system includes the  high walls and barbed wire of some 19 Israeli prisons and interrogation centres, most of them in Israel itself, in which Palestinians from the West Bank are held after being arrested, a process which usually takes place at about 2 a.m. to maximise the intimidatory aspect of the “swarm” of army and police who carry out arrests, and the humiliation of the family who are woken from sleep to lose one of their members, without being told a reason nor a destination, nor whether they will be tried in military courts, or subject to administrative detention without charge.  Conditions within the prisons are poor, and torture is so prevalent and taken for granted that the prisoners often do not even realise that they have been tortured.

IMG_4909 (1)



Thanks to the system of the Wall and to the even more comprehensive domination of Gaza, Israel is increasingly becoming a producer and exporter of weapons systems, torture techniques and surveillance systems that supply militaristic regimes across the world.  “People like to buy things that have been tested.  Israel sells weapons that have been tested, tried out.  It brings Israel billions of dollars.”  

IMG_4955Finance minister statement 2013 exhibit at Walled-Off museum

And the arms industry has become a key part of the Israeli economy.

IMG_4956Ehud Barak statement on arms industry exhibit at Walled-Off museum.





3).   As a symbol of abuse/military domination:

  The wall in Abu Dis and Bethlehem on the West Bank side has art on it, but this use as a site of expression merely modifies slightly its own enormity as a sculpture, a physical representation of absolute entitlement, an entitlement based more obviously than the entitlements that we are familiar with in the UK, that of ex-Etonians for example, on brute military force.  This sculpture reminds us that at the heart of capitalism is the absolute entitlement to land and property, and that entitlement’s proper expression is a Wall.

IMG_2700*** [art on wall at Bethlehem photo]



So what are the Entitlements  manifest in the Separation Wall:

1) … racialise populations – to make them be Arab or Jew and for those socially constructed categories to  be in a conflict to which all the other wealth of people’s identities and character is subordinate.  Ironically this has involved entirely eliminating as a cultural group the Arab Jews who once, as in many other surrounding territories, formed a substantial proportion of the indigenous population and, in places like Hebron, for example, were anti-Zionists.  It is a tribute to hegemonic power that most of the people we spoke to in the West Bank referred to themselves as Palestinians, and to their oppressors as Jews.  It seemed easy to applaud the former identity as a manifestation of solidarity, and to accept, albeit with hesitation, the racist identification of a whole cultural group with settler-colonialism and domination, as an understandable reaction to oppression – the oppressor has to be named, after all, and with a simple formula.   The tragedy of this naming of sides and the drive to identify with one side or the other is that this process,  this racialisation, is itself a product of the violence that engendered the categories

 2)… steal some of the best agricultural land at the edges of the West Bank.

3)…. to steal water and then severely ration it, particularly in the summer – two hours a week – whilst it is pumped freely to the settlements.

IMG_4880 (1)Water containers on the rooftops – the marker of a West Bank Arab community.


 4)….. to cut off people from their employment or from the means of employment, and to create a subordinate workforce of people who are working in a territory that they are not entitled to be in, thus encouraging employers to exploit them even more ruthlessly.  An estimated 1200 Palestinians are forced to cross the wall without papers every day, risking death or arrest.

IMG_4936Exhibit of one man’s account in Walled-Off Hotel.


5)…. to humiliate and bully people crossing checkpoints.  To have checkpoints operative randomly, but also fixed checkpoints that are only staffed and used to delay and harass non-Israeli travellers at rush hours, undermining the claim that they are for security purposes.


6)…. to engender fear and anger in the dominated population, as often as possible and in as many ways as possible, and then to use the perception of this rage by the racialised dominant group to justify more violence and more oppression, as we’ve seen in the recent Israeli elections.

7)…to use unlimited and often murderous military force in the name of the State, whilst refusing to recognise the targeted population as citizens, even though they pay fines and they pay taxes and they pay extortionate utility bills, in fact they pay more towards their own domination than do the Jewish Israelis, especially the settlers who are often exempt from taxes and from utility bills.


(86) Facebook (1)Settlers with assault rifle in the countryside.

8.) ….to use economic levers, corruption, informers, criminals and the desire in a class system to cling to past privileges to try to create a collaborating class amongst the indigenous population.



Domination engenders RESISTANCE.  

Not all bullying and domination leads to what we can recognise as resistance by the subaltern party – child victims of abuse, for example, may become perpetrators themselves or they may enter a long period of self-harming behaviour.    In the West Bank, however, the inescapability of the racist domination to which people are subjected means that it really is a collective experience.   Mimetic individualised reactions, such as those of the adolescents who try to stab a guard at a checkpoint with a knife or a pair of scissors – such children are nearly always killed immediately – are not stigmatised, they are seen as martyrs practicing resistance, albeit futile.  Their sacrifice represents and enacts the whole community’s refusal of subordination through military force. 


Naji Salim Hussain al-Ali, a Palestinian cartoonist, assassinated in London in 1987, created this figure of a ten-year old boy, Handhala, which has become an icon of Palestinian resistance.


In this context, just remaining alive, experiencing joy and love, is resistance, but what we were really privileged to experience as visitors was a remarkable hospitality extended towards us, a sample of what Abdulfattah Abusrour, director of the Alrowwad Centre in Aida refugee camp called “beautiful resistance”, which involves cultural performance, expression and communication in engendering solidarity.



Mural outside Alrowwad Cultural and Arts Society, Aida Refugee Camp, Bethlehem. Layla and Majnun is a narrative poem composed in 584/1188 by the Persian poet Niẓāmi Ganjavi based on a story about the 7th century Bedouin poet Qays ibn Al-Mulawwah and the woman he loved  Layla bint Mahdi, who was kept from marrying him by her father.

4). The Separation Wall and its system as export and as prophecy.

If the above list of entitlements has a familiar ring to it, here in London, once the capital of a system of imperialist domination, it is because they are the traditional entitlements of settler-colonialism. 


We live in a historical phase when the class that owns the vast majority of the world’s wealth is internationalised through capital mobility;  the brutal systems of direct accumulation by dispossession and enslavement in the periphery that always were a fundamental part of the system of industrial capitalism – but too little attended to in socialist theory –  are returning, like a tide, from faraway continents into the old imperialist heartlands, just as they did in 1930’s Germany and Italy.


This Separation Wall in Palestine  is a representation of what we, as socialists and internationalists, are up against all over the world, and of its modern methods of control in which Separation – i.e. racism – and militarism; the brutal irrationality of force, are key.  It is a physical representation of the huge edifice of domination that we have to undermine without ourselves resorting to bullying, torture, political imprisonment, and military force, in the brief time we have left before they destroy the planet.   What once was Palestine is an epicentre of strategies of domination, through techniques of racialisation, through the creation of different bands of citizenship with different levels of entitlement, through physical walls and systems of surveillance, through killings and detentions, that is being rolled out across the world to enable the system of gross inequality to survive and to develop as it engenders crisis after crisis.


IMG_4904 (1)



Court of Appeal hears how NHS England’s Accountable Care Organisation contract is not in public interest

via Court of Appeal hears how NHS England’s Accountable Care Organisation contract is not in public interest

Proposed Motion on Agricultural Policy for Labour Party meetings

Motion proposed to —insert Branch— Labour Party on agricultural policy:

This Branch notes that the EU’s common agricultural policy, a farm subsidy system that spends £44 billion a year, has promoted environmental destruction across Europe.   Because payments are made for any land that is in ‘agricultural condition’, there is an incentive to clear wildlife habitats even in places that are unsuitable for farming.  Because the more land you have, the more public subsidy you get, this system subsidises wealthy large landowners, even if they do not live in the EU.  This has encouraged a form of benefit tourism by the international super-rich.

This branch/CLP notes the lack of an agricultural policy in the 2017 Labour Manifesto.  The government proposes that after Brexit, farmers in the UK should be paid for protecting wildlife and ecosystems, including soil and water quality, rather than just for owning land, which would be some improvement on the present system, but this still is using subsidy as a substitute for regulation, paying out public money without achieving public ownership or any other form of democratic control of land.

The Branch calls for the development by the Labour Party of a coherent agricultural policy based on some basic principles:

  1. Restoration and improvement of systems of monitoring and regulation of agricultural and environmental practices, including regular inspections and better protection of sites of special scientific interest.
  2. Failure to meet regulatory standards to be met by compulsory purchase, replacing private with democratically accountable communal ownership.
  3. Urgent action to return land on which sustainable agriculture is relatively unviable to natural re-wilding to allow for reforestation, trapping carbon and restoring degraded landscapes.
  4. Agricultural land to be protected from use as a financial asset at the expense of its use for communal benefit (either for food or for environmental protection and diversity).  This could be achieved by imposing a high capital gains tax paid on transfer of its ownership, and by including land in a wealth tax.

The destructive efficacy of domination – a review of “The Death of Homo Economicus” by Peter Fleming, Pluto, 2017.




Peter Fleming is professor of business studies at City University, London.  His 2017 book, The Death of Homo Economicus, is full of stories of people destroyed, hurt, or marginalised by the current ‘corporate hellscape’ of vulture capitalism and the ‘wreckage economics’ that he describes with the metaphor of the destructive backwash that followed inevitably from the devastation of the 2007-8 economic tsunami.    Homo Economicus is the mythical creature, the illegitimate offspring of Adam Smith, rationally making choices in a market that needs and tolerates little or no intervention from the state, a creature whose false foundations shattered when financial markets around the world had to rescued from impending collapse by state intervention.

Fleming illustrates the death-giving power of an already-dead extractive capitalism with the grim story of the suicide in 2013 of Aaron Schwarz.  Schwarz was a US computer genius hounded by the hybrid power of big business and the state – a hybrid that in itself contradicts the myth –  after he  attempted to liberate to academic readers the knowledge that they had been forced to surrender as writers to corporate publishers and which they could only then access again by paying huge fees.   This corporate extortion in collusion with the state betrays the promises that IT once made to liberate knowledge from the clutches of ownership, contrary to Paul Mason’s idea that technology can deliver freedom from work and production with zero marginal costs, and thus free us from domination by wealth.  Instead we have the ironically named ‘sharing economy’ in which extraction thrives on desperation, collective bargaining is fettered, student debt and housing debt engender a new peonage, and millionaires are made through owning online prostitution sites, where there is no regulation and the consumer is king.  Such sites are just one example of work extending into everyday life.  

Characteristic of this ‘new Dark Age’ are investor vandalism (Carillion), debt financing, state engineered profiteering through corrupt underpricing of public assets for sale, as with Royal Mail, and the feeding frenzy of tax avoidance summed up neatly by the fact that 80% of global trade consists of transfer pricing, that is, corporations trading with themselves via subsidiaries and shell companies in a different tax zone.   Innovation stumbles due to lack of investment in research and development, and workers focus on metrics rather than their tasks, as in the colonisation of universities by a business analogy; where, as in the NHS, the mythology of the customer is used to undermine public service, so that failings are blamed not on underfunding and excessive workload, but on individuals or understaffed institutions.  Public institutions, from transport systems, to housing, health care systems, schools and universities, have been systematically financialised, whilst the concept of public service has been vilified.

Fleming equates the death of the mythic Homo Economicus – a persona the 1% never identified with themselves – with real deaths – those who die shortly after the DWP has declared that they are fit for work, suicides attributable to overwhelming student debt, the murderous revenge of people made redundant.   Fleming mobilises Engel’s concept of social murder when the system of domination, the transformation of instrumental means, such as money, prices and the quantification of social behaviour, into ideological ends  leads to early and preventable deaths; he wrote the book before the Grenfell fire provided such a harrowing and clear example of mass social murder.  He cites David Graeber in condemning as inherently stupid the extra layers of bureaucracy required to police an increasingly unequal society, which stems from their deriving from state power that monopolises violence, a stupidity that can brazenly avoid interpretive labour in its dealings with the powerless and push that labour onto the victims; however, for Fleming, this does not go far enough in describing the institutionalised sadism that is being encouraged, taught, and measured – in the DWP for example – where the aim is not just to erase the subjectivity of the victim, but to occupy it.  

Work is a cultural and ideological artefact, pushed to an individualistic limit where employed or unemployed are made to see themselves as a ‘Company of One’ (Carrie Lane, 2011) subscribing wholeheartedly to the system that has crushed them, seeking an alibi in pointless and demeaning work that in itself signifies waste, facilitated by state-sponsored over-employment.  Fleming evokes the Auschwitz gate slogan Albeit Macht Frei for this militarised workforce in which Weber’s Protestant aim of divine redemption through work has been replaced by a huge absence, by a victimhood that both the dominators and the dominated can see as manufactured, that is, by sadism.  Neoliberal economics, for Fleming, is a fascism of money, that he describes as ‘the unreal reality that emerges when economic theology tries to make its madness real’, when labour is considered simultaneously as essential and as superfluous, so that the capitalist aim is always to get something for nothing, to be independent of labour but to have it always on tap, with zero reproductive costs.  Mike Ashley’s Sports Direct warehouse regime in Bolsover is one such  (EU-funded) death camp.  He reminds us that work does not exist in subsistence economies, it emerges as the state emerges, needing the latter to make people produce a surplus.  To work is already to overwork.

Underpinning the individualisation of work is Human Capital Theory, the idea that a person is the carrier and developer of skills, knowledge, education and attributes that are their property from which they cannot be separated – the neoliberal argument for people investing in their own education and training, leading on to lifelong insecure self-employment, even if it then has to be subsidised by the state.  This regime is in fact a form of divestment, with severe diminutions in the supply of talent, no career development paths, boredom and a new authoritarianism and gender-based workforce abuse, as laid bare at Shirebrook or in Amazon warehouses, but characteristic increasingly of workplaces everywhere.

Steven Slater in 2010 was an airline cabin crew member who exploded with rage when hit by luggage let fall by impatient and argumentative passengers, activated the emergency chute system and fled the scene.  This story Fleming uses to typify the effects of an inclusive form of capitalism in which the economy is both more than us and part of our personalities and relationships, leading to self-harming behaviours and often a violent and drastic snapping.  The depression and quietude that comes from being trapped by an all-encompassing ideology is interrupted because the current system insists on workers being aware of their own futility, making an empty ‘outside’ part of the totalisation, inculcating exit fantasies (moving to France is cited as one such, which I myself indulged in) that may involve doing something really desperate.  As in the battered spouse syndrome, people become more and more dependent on, and even attracted to, institutions that inflict pain.  As Deleuze observed, domination alienates people from their potential to act and do beautiful things, negative power separating us from our potential;  Agamben sees further that it can also separate us from what we can not do, from our capacity to refuse, and this constitutes a further pressure to seek a means of escape.  In the absence of collective strength, this escape turns us into a hunted quarry, the totally individualised subject of surveillance by the state and the police.  Providing sanctuary for such escapees is the basis for a political community to emerge.  Fleming makes an important parallel of such resistance with the recessional resistance, the withdrawal, of the natural world all around us…we experience in our minds and bodies qualities that can be identified in dying ecosystems. ‘Isn’t mimesis the basic code of life?’ Fleming asks, echoing my own conclusions about the relationship between people’s self-damaging health behaviours and their experiences of domination after three decades of working as an inner-city GP.

For Fleming the means/ends inversion that has always been a feature of capitalism is now deeply institutionalised.  He writes that his own academic specialty – ‘economics’ – has the same vacuity at its heart.  Fleming espouses a deep pessimism, but attempts to find the basis for a countervailing “optimism of the will” so that the book ends on a note of exhortation. ‘The growing winter of a wasted world, a vapid monoculture of nothingness, is encircling us as we speak, and it’s time to leave.  That ticket isn’t going to be served on a paper plate.  For the future to begin again and history to be made, one has to be correctly poised.  Be ready.  And therein lies the most important question: will we ever be worthy of that history, still yet to come, but certainly demanding a response from us very soon.’

After so many examples of victimisation, of the damage to more or less all of us, inflicted in the name of domination and the supposed necessity of accumulation this call to be worthy, which pointed by Fleming in the direction of solidarity and of providing sanctuary to our fellow victims, signals a cruel contradiction.  How can we be ready or be worthy, be healthy or collectively strong, when we have already been so cruelly and damagingly subtracted from?  When self-damaging behaviours and escape fantasies are so ingrained? Isn’t mimesis the basic code of life?  

Those of us who are relatively undamaged have a heavy responsibility, which must be a political movement, a Mont Pelerin Society pushing in an entirely opposite direction, away from the market, away from commodities, away from production and exchange, and towards the cultural elevation of nurture, of basic social reproduction of our species and the environment of which it is a part – here mimesis of our childhood nurture, with the exception of the victims of child abuse (and the victims of so-called Public schools) makes us not into Homo Economicus but into carers.  Whilst accepting the myriad forms of individuals’ experiences of abuse, and the many modes of domination that its victims experience, whether raw present or recent violence, or the traces of history that generate social class and other domination hierarchies – of nationality, citizenship, race, gender, and sexuality, we can strive to grasp the essential unity of negative power and its effects on the health of individuals, of communities, and of the environment, its negative effects on our own ecosystem.  This involves articulating the mimetic potentiality of domination, that creates the link between the personal and the political – the relation of rape to gender, for example; articulating  its clear distinction from positive modes of power,  nurture and education, caring for the damaged and disabled, the culture of ourselves and of our environment – that is, attempts that aim for a positive effect upon the capacity of other beings and things to exist and to develop freely. 

We make judgements all the time about our own behaviour but if we remain well enough we can condemn certain actions, regret them and avoid them without condemning ourselves,  and our judgements about others should show the same tolerance, even of the 1% who are addicted to the crazy accumulation which has to be stopped if our societies are to survive.   “Justice for Grenfell” does not mean locking up the perpetrators, as some of the marchers at the anniversary of the fire were demanding, but it means ending the control of housing provision by negative power.  The  habit of stigmatisation of victims must mutate into stigmatising the activities of the perpetrators; this means identifying, vilifying and suppressing (insofar as it is possible) all modes of domination; it means creating a society in which the positive power of nurture and community exemplified by the solidarity in adversity and loss displayed after that mass social murder in the Grenfell fire is generalised and multiplied.  This involves placing social reproduction, on which capitalism and the market have always been parasites, on an ideological and practical footing  above the production and exchange of commodities, that is, the end of survival – (Spinosa’s conatus) above the means of money and accumulation.  We need an internationalism not of workers alone, but of all the nurturing, the educating, and the caring,  and their advocacy for the stigmatised, the disabled, and the weak.  We have to try to celebrate as resistance all resistances even when they are self-harming, show solidarity, provide sanctuary, and bring those resistances back into the fold of a collective and more effective resistance.  

We cannot hope for a society free from violence, but we must before it is too late try to make one in which violence and bullying – negative power in all its forms –  are identified and stigmatised, which means, amongst many challenges in the many fields of entrenched injustices, finding ways to make wealth worthless and borders meaningless.   In terms of the ‘housing crisis’ this does not mean necessarily that we need to confiscate land and property, we just need to make the rights of occupiers and users of property greater than the rights of owners, then the owners would no longer want their surplus property that could no longer be used for extraction;  for economic capital some parallel process could make funds available for all projects that were creating a public service and demonstrably not exploiting people – both at home and abroad; a global period of massive hyperinflation might result and shrink all those piles of accumulated claims upon future society, that hopefully the owners would no longer really want, down to a manageable size.  A project of reparation for Africa and for all the other zones of abjection that we have created around the world, at the same time as we turn to really caring for and helping the sick and the disabled and the homeless, as well as cosseting the environment back into a stable sustainable state would certainly provide plenty of real work for the foreseeable future however much technology is brought to bear.

 A healthy society is a materially equal society, in which having no power to control other people is positively celebrated and jealously guarded.  For such a pre-Neolithic, pre-surplus  social structure to work in complex and crowded societies we do need to embrace technology and we need to acknowledge that it, and the knowledge that it represents and bears, belongs to everybody.  If all of us have a little property, we cannot be allowed to use it for purposes of domination without risking stigmatisation and sanction.  This requires clarity, mass agreement and enforcement through the power of collective strength, not about what is morally right or wrong, not about our own or others rights, but broadly about what contributes to human and environmental flourishing and what, on the other hand, constrains and destroys it.  

Homerton Hospital becomes a ‘hostile environment’:


Clearly designed to intimidate anyone who is at all unsure of their citizenship status, this form for people coming to Homerton Hospital in Hackney, even to the A&E department, is aimed at deterring them from seeking treatment, even the emergency immediately necessary treatment to which all are entitled.  This intimidatory bureaucratic barrier to care takes no account of public health imperatives that should prioritise the health of the whole community, nor does it take account of the right (and the ethical duty) of health care workers not to be acting as border guards and police.