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New Labour, New Language?

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reviews
BOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS • MINERVA

New Labour, New transformation?). Some are undefined: curiously fails to note this fact, he does point
“work” and “change.” And some involve to what he calls the reality-rhetoric
Language? shifts in meaning: “trust” (defined as the dichotomy, exemplified by the contrast
Norman Fairclough “recognition of a mutual purpose”) and between rhetoric about open government
Routledge, £9.99, pp 178 “dialogue” (which means not discussion but and the restrictive reality of the Freedom of
ISBN 0 415 21827 6 diatribe). Even “the” is not exempt—it is used Information Bill.
to give verisimilitude to non-existent entities Lest you doubt his interpretation,
Rating: ★★★★ (“the international community”). Other wea- Professor Fairclough presents the
sels need no gloss: “quality,” “evidence,” evidence—an analysis of word counts and
“governance”—we have all come to know collocations in two bodies of writings and
what they mean, or think we have. speeches, one from new Labour and one
But some of this subtlety subverts itself.
from the old left. He shows how words like
When Blair evokes “joined up government”
reform, business, values, and work are no
has he forgotten that joined up writing is
longer used to mean what they once
what children aspire to but adults consider
did—that the weasels have got more weaselly.
trivial? Probably—politicians are too often
Disappointingly, he fails to compare these
fooled by their own rhetoric (remember Mrs
two bodies of texts with a comparable body
“I
can suck melancholy out of a song,” Thatcher’s famous pronouncement that “we
says Shakespeare’s Jaques, “as a weasel are a grandmother”?). And when he talks of right wing texts (although he does
sucks eggs.” Hence the phrase “weasel about the “third way,” does Blair really want occasionally cite Mrs Thatcher and Presi-
words,” coined for political purposes in the to raise echoes in our minds of the Third dent Clinton for comparison). Nor does he
United States at the end of the 19th century World—countries that we used to call under- point to the rhetorical device of talking
and used (most famously by Theodore developed? Or even the Third Reich? about “the old left,” which is pejorative,
Roosevelt, criticising President Woodrow Some of the rhetoric is even derisory. rather than “old Labour,” which has a
Wilson) to describe rhetoric that sounds as if “The Tories stand only for the privileged resonance of its own.
it has substance but is actually empty of few,” says Blair. “We stand for the many.” Now But the message is clear. If you don’t
specific meaning, or is at best ambiguous and this is just a rehash of Mr Spock’s Star Trek want to be too weaselly misled, look out for
vague. All competent politicians know, often dictum that “the needs of the many the weasel words and structures in every-
purely instinctively, how to coin weasel words, outweigh the needs of the few.” But in the thing you read. Look for them in the politi-
or at least how to use them. But none is as hands of new Labour’s rhetoricians, such cal manifestos, in executive directives, in the
good at it as Tony Blair and “new Labour,” trite sentiments are intended to catch votes, next letter from your friendly consultant. Oh
according to Norman Fairclough in this pen- not to express real policies. The rhetoric cre- yes, and even in book reviews.
etrating disquisition, refreshingly free of ates the policies, not the other way round.
sociolinguistic jargon and bolstered by lin- Indeed, the rhetoric hides the absence of Jeff Aronson clinical reader in clinical
guistic evidence and analysis. policies. Although Professor Fairclough pharmacology, Oxford
Some short words make superb weasels.
Like “we.” Not much ambiguity there, you
might think. But “we” can be completely
exclusive (the royal we, the authorial or edi-
torial we) or completely inclusive (every-
body). And in between are all shades of
grey—I, you and I, the Cabinet, the
government, parliament, the country, the
world, the solar system, the universe. The
trick is to make the meaning slide ambigu-
ously from clause to clause, from sentence to
sentence. Don’t specify who “we” is, and
everyone feels included. Inclusion, after all,
makes you part of new Labour’s “one
nation,” what John Major less successfully
described as a classless society. It also means
that you can participate in “public-private
partnership”—in other words, privatisation.
And it contrasts with “social exclusion”—
what we once called poverty. The Tory party
used to call itself the natural party of
IAN STEWART/AP PHOTO

government; now, by pandering to our

desires to be included, new Labour tries to
claim that unrealistic role for itself.
Some other weasels also bare their teeth
ambiguously: “values” (economic, political,
or moral?) and “reform” (destruction or “Britain deserves better.” But did it deserve New Labour?

1480 BMJ VOLUME 320 27 MAY 2000 bmj.com

 reviews

Caring for Women with tion in the second stage of labour. Instruc- The different types are clearly described in
tions were faxed over from another state, the book, supplemented by a laminated
Circumcision: A Technical and the baby was delivered successfully. sheet of illustrations and diagrammatic
Manual for Health Care This case history from Toubia’s book instructions for defibulation. Although the
illustrates some of the difficulties encoun- classification of circumcision is precise, Tou-
Providers tered both by affected women and by bia comments that the performance of the
Nahid Toubia doctors. Toubia writes as an African woman surgery frequently is not, as it often involves
RAINBO, $17.95, pp 94 and a physician, and her manual provides a traditional circumciser, poor lighting, and
ISBN 1 893136 01 9 concise and accessible coverage of the an unanaesthetised child who is screaming
Rating: ★★★★ cultural, physical, and emotional complexi- and wriggling.
ties of female circumcision. This is also, The practicality of this book extends not
more controversially, termed female genital only to the medical, gynaecological, and
mutilation; Toubia considers that both terms obstetric needs of those circumcised but also
have their place, with “female circumcision” to the section on communication. This is
being more useful in the clinical setting. masterly, with cogent advice on topics such
Female circumcision affects about 100 as asking about past circumcision, giving
million women and girls worldwide. Their information (use pictures for women with
risk of dying in childbirth is doubled and of low literacy), and employing interpreters
having stillborn babies trebled, and other (avoid using patients’ children). The section
physical, sexual, and relationship problems

A
19 year old Somali refugee woman on the law has been written for the US
presented in labour. She spoke no are common. Although female circumcision market but also summarises the position
English. Examination of her vulval is now illegal in many countries, the practice elsewhere.
area showed a long scar in place of her continues in much of sub-Saharan Africa, This is a valuable reference for a topic
external genitals, with only a tiny opening. among various religious groups, as a rite of poorly covered in mainstream textbooks
The senior resident called to advise thought passage into womanhood or a way of and is a compelling read for clinicians who
that he remembered hearing about ritual preserving virginity until marriage. wish to develop the skills to manage affected
cutting, and managed to track down a The extent of physical damage ranges women capably and sensitively.
colleague who had worked in Somalia. Over from a clitoral nick to complete infibulation,
the telephone, she explained that the when the external genitalia are removed and Jan Welch consultant, Department of Sexual
woman was infibulated and needed defibula- the vaginal opening narrowed by stitching. Health, King’s College Hospital, London

The River: A Journey Back The earliest identified isolate of HIV-1 for a major review of the vaccine hypothesis
comes from an unknown male in Kinshasa, and the testing of any remaining stocks of
to the Source of HIV and Congo, in 1959. The first identified patient those vaccines for infection with HIV or SIV.
AIDS with HIV infection and AIDS was a Scandi- Whether the proposition is true will
Edward Hooper navian man in the 1960s, who had visited become clear as more primate SIVs are
west-central Africa. Then came sporadic genetically sequenced and correlated with
Penguin Press, £25, pp 1070 HIVs over time and place. My personal feel-
ISBN 0 713 99335 0
cases among gay men in the United States
and among Haitians in the 1970s, leading to ing is against the hypothesis on the grounds
Rating: ★★★ the global explosion in the ’80s and ’90s and that it is too simple an account of the evolu-
the literal decimation of peoples in several tionary complexities of these lentiviruses,
tropical countries. Did the transmissions of and the fact of more than one introduction
SIV across species—and there were two or of SIV or HIV into humans. However, it is
more some time earlier last century—come possible in principle, and finding out the
about through close contact between truth is important because of the implicit
human hunters and their primate prey (dis- threat to vaccine programmes in the future.
secting or eating), or might the pandemic This magnum opus from a non-medical
have arisen from a medical accident? investigative journalist should stand for other
The hypothesis of this book is that the reasons. It is the best yet historical description

D
oes it really matter how AIDS of AIDS. It is a detailed examination of a great
drive to conquer another scourge, polio, is
started? Not long after AIDS was episode of medical endeavour (the polio vac-
the crux. The preparation of live attenuated
described in the United States, cine), and also shows how we can cut corners
oral polio vaccine originally used cultures of
Europe, and Haiti, it became evident that when it suits and fail to document much
monkey kidney cells; there were monkey
several countries in sub-Saharan Africa had methodological information (it is not certain
laboratories in Africa devoted to testing
far greater proportions of people already whether cultures of chimpanzee kidney cells
affected. The belief emerged that the human these vaccines and providing kidneys for the
were used in the final stages of vaccine
immunodeficiency viruses arose in Africa. vaccine factories; the kidney cells (or associ-
production).
Thanks to molecular technology, the HIV-2 ated lymphocytes) could have been infected
Yes, it does matter how AIDS started,
virus, mainly limited to west Africa, was by SIVs that could adapt to humans and and this book is a contribution to the debate.
found to be identical in genome organis- cause disease (which they do not in their
natural hosts); then administration of oral Sebastian Lucas professor, department of
ation to a simian virus (SIV) in the local
polio vaccine infected adults and children histopathology, Guy’s, King’s, and St Thomas’s School
sooty mangabey. Evidence accumulated of Medicine, London
about the close relation between the now with SIV during the mass trials in the late
pandemic HIV-1 and chimpanzee SIVs in 1950s.
The idea is not new, having been The BMJ Bookshop will endeavour to obtain
central Africa. any books reviewed here. To order contact the
How did the viruses transmit from mon- proposed in 1992 (and rubbished or BMJ Bookshop, BMA House, Tavistock Square,
keys and apes to humans, to cause the most deflected by the scientific community). What London WC1H 9JR.
important zoonosis yet known? And when? Hooper has done is to show a striking Tel: 020 7383 6244, Fax: 020 7383 6455
geographical and temporal correlation email: orders@bmjbookshop.com
between the earliest known and probable Online: bmjbookshop.com
Reviews are rated on a 4 star scale (Prices and availability subject to change by
(4=excellent) cases of AIDS and the sites of administration publishers.)
of polio vaccine in central Africa. He presses

BMJ VOLUME 320 27 MAY 2000 bmj.com 1481

reviews

mate task of combating malaria, tuberculo- “The dangers of this are illustrated by
sis, and other infectious diseases. the WHO’s ‘Tobacco free’ initiative, and its
It would be convenient to assume that current attempt, eagerly pursued by Dr
the authors of these articles were all in the Brundtland, to secure a draconian conven-
pay of the tobacco companies, but no such tion against the tobacco industry.” Scruton
evidence exists. But it is still worth address- claims that the grounds for this are largely
ing the arguments of people who attack the spurious and will lead to massive legislative
WHO for taking on the tobacco industry, and policing powers being given to unac-
Vilified for tackling because the debate is bound to run and run. countable bureaucrats and to the trade in
The main opponent of the World Health tobacco going underground.
tobacco Assembly’s actions is Roger Scruton, the Although Scuton’s arguments hang
libertarian writer and philosopher who together logically (as befits a former
was until recently a professor at Birkbeck philosophy don), some of the statements on

A
n organisation dedicated to “impos-
College, London, and now makes his living which he bases his arguments do not stand
ing its will” on people across the
as a writer and runs an experimental farm. up to close scrutiny. He claims, for example,
world and “undermining property
Scruton has produced a paper for the Insti- that although smoking is a risk to health, “it
rights” met in Switzerland last week. It was
tute of Economic Affairs (a right wing is perhaps less of a risk than eating junk
criticised in the Wall Street Journal Europe as
British think tank), entitled “WHO, what and food.” What evidence is he using to reach
undermining individual choice and in the
why,” which is cited in the Times leader and such an outlandish conclusion? And when
Scotsman as “leading to a version of 1984.” So
which is the basis of the Scotsman article. he claims that the numbers of deaths from
what was the name of this sinister body? Was
Moreover, many of his arguments are smoking have been exaggerated, what statis-
it the Mafia? Or the Freemasons? Or a new
repeated in the Wall Street Journal piece. tics is he using to counter the powerful
socialist terrorist organisation dedicated to
In his paper, he argues that trans- collection of figures produced by Richard
the overthrow of the capitalist system? No.
national institutions are increasingly exercis- Peto and others in such books as Mortality
As it turns out, it was the World Health
ing their legislative powers, in order to from Smoking in Developed Countries 1950-
Assembly, which was meeting in Geneva.
bypass the constraints to which national leg- 2000?
Why did the assembly (the annual
islatures are subject. The situation is made He also claims that tobacco is of no rel-
general meeting of all the member states of
worse by the habit of conferring leadership evance to people in developing countries,
the World Health Organization) provoke
of these institutions on former politicians, because smoking related disorders affect
such ferocious criticism, prompting a leader
people only in later life, and average life
in the Times, a long feature in the Wall Street such as Dr Gro Harlem Brundtland, the
expectancy in many such countries is only
Journal Europe, and a half page article in the former prime minister of Norway who is
45. Yet he fails to recognise that this life
Scotsman? Its crime, according to these now the director general of the WHO. Such
expectancy figure is low because of the high
distinguished newspapers, was that it had former politicians tend to be more respon-
number of infant deaths, and that plenty of
decided to “take on” the tobacco industry, sive to the concerns of vocal but unrepre-
those people who survive into adulthood
instead of confining its activities to the legiti- sentative interest groups, Scruton claims.
live quite long enough to be affected by the
diseases of smoking, such as lung cancer,
emphysema, and heart disease.
He fails to address entirely Richard
Urinary tract symptoms This week the BMJ publishes a paper (p 1429) and a Peto’s prediction that although smoking is
linked editorial (p 1418) that show that lower urinary tract symptoms in middle likely to increase deaths in developed coun-
aged women are common and that they relapse and remit. It’s a salutory read tries by only 50% in the next 25 years (from
for anyone who doubts the size of the overlap between “health” and “disease”: 2 million to 3 million a year), it is likely to
from an epidemiological perspective, asking patients to list urinary symptoms increase deaths in developing countries by
WEBSITE seems to be an act of even less diagnostic sensitivity than was previously 700% (from 1 million to 7 million a year).
OF THE imagined. Finally, his claim that the WHO is not
accountable to national governments is
WEEK If there can be such a thing as a classical field of inquiry on the internet,
flattened in one sentence by Dr David
then urinary incontinence must surely be one: it’s an embarrassing problem
that many people would rather discuss in the safety and anonymity of the Nabarro, an executive director of the WHO,
online environment. The BMJ has already published a paper that shows that who replied to Scruton’s polemic in a counter
much of the information and advice available online in this area is of good article in the Scotsman. In it, he said: “WHO is
quality (www.bmj.com/cgi/content/full/319/7201/29). It takes more than good directly governed by its member states and Dr
intentions to build the kind of online communities assessed in that paper
Brundtland is an elected—not appointed—
official . . . The WHO secretariat is responding
though: the author of “A guided tour of self help in cyberspace”
to its member states,” who said that they
(http://odphp.osophs.dhhs.gov/confrnce/PARTNR96/ferg.htm) argues that
found it hard to regulate the tobacco industry.
such communities are contemptuous of the “shovelware” (material created for
They found that tobacco companies could
paper then converted uncritically to HTML and shovelled onto the web) that
circumvent advertising restrictions, health
many health providers provide on their websites. regulations and taxation rules and exert
It may be unkind of me to suggest it, but www.incontinencenet.org/ falls tremendous pressure on governments, which
into this category. A frames-based site that is paradoxically tricky to navigate, it are generally ill-equipped to deal with their
has evidently been heavily sponsored by the pharmaceutical industry: all that wealthy marketing machines.
fancy graphical design does not come cheap. But IncontinenceNet fails a The ironic aspect of the Times’ attack on
crucial internet test—it has little evidence of community: one or two sad the WHO’s “political correctness” is how
questions languish unanswered in its “chat” forums. Its British equivalent, the reminiscent it is of its earlier opposition to
Continence Foundation (UK), has a useful basic site at www.vois.org.uk/cf/ but public health measures. When Edwin Chad-
you’ll have to write off to receive any of its publications in the post. wick tried to introduce clean drinking water
Douglas
Meanwhile, if you want to point patients in the direction of some high quality and better sanitation into 19th century Eng-
Carnall
resources, send them off to the US National Institute of Health (www.niddk.nih. land, a Times editorial in 1854 thundered:
BMJ
dcarnall@ gov/health/urolog/urolog.htm), where there is a collection of high quality, “We prefer to take our chance with cholera
bmj.com consumer level publications on many different urological problems. than be bullied into health.” Plus ça change.
Annabel Ferriman BMJ

1482 BMJ VOLUME 320 27 MAY 2000 bmj.com

 reviews

PERSONAL VIEW SOUNDINGS

Has humanity disappeared from the NHS? Be very afraid

I
t was Monday 27 December 1999, when There would, however, seem to be some “Beware the Jabberwock, my son,
I was the first on-call physician for the good news. The secretary of state for health The jaws that bite, the claws that catch . . .”
acute medical admissions unit at the has admitted that the reduction in hospital Danger can be obvious, something dark
Royal Infirmary of Edinburgh; it was to be beds, at least in England, has been excessive. and wicked, easy to perceive and to shun.
the busiest day of the year. But what if, as is likely, there is a disparate But, as any heartbroken lover will tell
There were heroic efforts from many perception held by doctors and managers of you, when it comes in the guise of
staff in containing what seemed to be a tidal what is an adequate number of beds, and something beautiful, something gentle
wave of patients—most of whom were occupancy figures are nearer 100% than the and kind, it is hard to recognise and
seriously ill. Paradoxically, I enjoyed the 24 ideal of 85%? It will be unfortunate not only avoid, and then it is perilous indeed.
hour period, unencumbered by the usual for patients who will continue to endure all Two of my patients died last week. I’d
other clinical commitments. It was like the that is unsatisfactory with the present provi- looked after them for years, and they
“good old days” when doctors and nurses sion of health care, but also for medicine as were good people and easy to be good
worked together rather than in parallel. a whole because of the intolerable burden of to, but I can’t pretend to have felt any
The next day there was a sense of working at, or near to, full capacity through- great grief over their deaths. Over the
elation: every patient was in a bed. But as I out the year. years I’ve got pretty hardy, not one to
visited the new patients scattered through- And what is the cost of this frenetic activ- blubber.
out the hospital it became ity? Doctors will be increas- We are not made of rock, but of flesh
clear that many had not ingly forced to cut corners and blood; we are not gods, just simple
been clerked, many were
I sense a climate with the inevitable rise in men and women doing our best. You can
not in appropriate beds, of fear in the cases of medical negligence. care deeply for your patients, like them,
many had been moved on They will not have the time be their friend as well as their doctor,
more than one occasion,
NHS, preventing to attend the lunch time and that’s as it should be, but there is a
and some of that boarding the admission of clinical meeting regularly, thin line to be crossed where we give too
had been instigated by bed will give this year’s specialist much of ourselves.
managers against medical
inadequacies in conference a miss, will fail to “Equanimity,” according to William
advice. the service engage in research and Osler, was what we should strive for, and
My experience was not audit, and their medical most of us do manage to muddle
unique, but what made that Christmas period journals will remain unopened. through somehow.
so memorable was the collective failure of It is not that doctors are workshy, but No matter how exquisite the pain,
management to recognise or, perhaps more they are frustrated that the system does not we usually walk away after our shift and
accurately, to admit that the NHS was in diffi- seem to recognise that time is necessary to forget about it, watching a game of
culties. It was the behaviour of directors, reflect on your activities if a high standard of football, having dinner with our family, a
trying to defend the share price of their com- care is to be delivered. There is an increasing few beers with friends. We go back to
pany ahead of the publication of poor results. anger that they have become the whipping our own lives. Yea, tho we walk in the
Not only did such a stance undermine the boys for the failure of an inadequately Valley of the Shadow of Death, once I’m
efforts of the clinical staff, but it also resourced service. out of the Valley it’s not my problem
concealed the true state of affairs from the At such times doctors look to the medi- anymore.
public. cal royal colleges and the General Medical But we do have to care a little bit,
I sense a climate of fear in the NHS, pre- Council for guidance in trying to maintain a and sometimes our profession can let us
venting the admission of inadequacies in the decent standard of clinical practice. How- down very badly. A tribunal is under way
ever, these potential saviours are on the back in the Republic of Ireland at present to
service lest it is interpreted as personal failure
foot, greatly exercised by how to counter the investigate the use of contaminated
with serious career consequences. And that
seemingly endless criticism of the medical blood products which led to many
fear has infiltrated beyond administrators.
profession. It is all very well to proclaim the people with haemophilia developing
Journalists are frustrated by the “don’t quote
merits of revalidation and of clinical govern- AIDS and hepatitis C, the cure
me” revelations of hospital doctors who are devastatingly worse than the disease;
concerned about their financial promotion. ance, but most practising clinicians have
little confidence that either of these projects, don’t trust me, I’m a doctor.
There is just a danger that they will lose the Whether this was a result of
independence which characterised doctors in as yet unfunded and somewhat ill defined,
incompetence or laziness or bad luck or
the past—at times counterproductive to will improve the lot of the patient, or indeed
lack of resources is not yet clear. We
progress, perhaps, but a guarantee that maintain confidence in the profession.
have only heard the patients’ side of the
patients had effective advocates. And these independent and potentially
story, and no matter how stark the
It was Aldous Huxley who said that fear powerful bodies have been quiet, at least in
tragedy it is too simplistic to look for
“casts out intelligence, casts out goodness, public, over the issue of resources. Surely they,
scapegoats; doctors are easy targets for
casts out all thought of truth . . . in the end too, cannot have become as fearful as the
blame.
individual doctor or manager of pointing out But what has clearly emerged is a
fear casts out even a man’s humanity.”
what has been glaringly obvious to anyone picture of an aloof, secretive, and
How else, other than in terms of loss of
who has needed to be in hospital recently. unfeeling profession. Even after the
humanity, can you begin to explain how we
There is within medicine an enormous talent mistake was made some of these patients
have come to accept, as the norm, mixed sex
and within management genuine commit- were treated with an offhand discourtesy
wards, with the delirious drunk adjacent to
ment to the NHS. Think how much better the that seems barely credible.
the elderly spinster in cardiac failure, her life
service could be if fear of failure and of stick- Surely this picture can’t be right;
ebbing away; boarding of patients in the
ing your head above the parapet were to be surely.
middle of the night and possibly on several
swept away and intelligence, goodness, truth,
occasions during a hospital stay; and the Liam Farrell general practitioner, Crossmaglen,
and humanity allowed to flourish.
inappropriate early discharge to relatives ill County Armagh
prepared to cope? Anthony Toft consultant physician, Edinburgh

BMJ VOLUME 320 27 MAY 2000 bmj.com 1483

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