The People's Cries

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

Month: June, 2020

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