All of us adopt or are involved in building patterns of ideas about the world and what we do in it. We use those ideas to help us understand what we are doing in the world. We see the world in the way our culture understands it. We build our lives using them. They become a part of who we are. This makes these ideas and understandings about the world critically important to us and we will defend them. Sometimes, if they are important enough to us, we will defend them with our lives.
We talk about cultures when referring to the patterns of ideas as well as to the groups of people who embrace them. Depending on what we do and the groups we form we will have subcultures within cultures. Cultures and subcultures may be similar and work together or they can be very different and conflict with one another.
We use these patterns of belief to understand what life is about and explain what we do, but this does not mean that they are based on fact or on logic. If you look around at the variety of belief systems people adopt its quite clear that many of them are not logical or based on any sort of verifiable fact. They can't all be correct, some are simplistic and many are obviously wrong.
Beliefs enable us to do something in a complicated world even when the ideas we believe in don't explain it fully. We cannot exist without them. Mankind has developed and prospered by using them. But they don't always work and not infrequently society and its members can be harmed by the things a belief system requires people to do. Witches were burned at the stake and non-believers have been killed or tortured to force them to believe.
Evidence and logic: Cultural beliefs can be confronted by fact and logic. These can be used to change or modify belief systems but when they directly contradict or challenge that belief system it is more likely that they will be denied or ignored. It can be difficult to get people to change. Look at what happened when someone found out that the world was round and not flat.
Further explanation: In 2011, I wrote a criticism of the Productivity Commission report 'Caring for Older Australians'. I wrote a simple common sense introduction to explain basic ideas and principles that would be helpful in understanding my criticisms. I followed with a brief history of health and aged care before returning to the changes that have occurred and the conflicts they have caused.
This may be a useful background to these pages for those who are unfamiliar with elementary logic and more theoretical cultural ideas. It is a good introduction to these pages, particularly if you find you are struggling.
- A Basis for Criticism comprising A Simplified Understanding of the nature of Ideas, Beliefs and Behavior and A Simple History of Ideas in Health and Aged Care Corporate Medicine web site 2011
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Ideology: A belief system developed by a group of people in one section of society can become so real and so important to them that they come to believe that it is universally applicable, will work everywhere, and so can be applied to all of society. They usually believe in it almost like a religion and seek to convert others. They apply it across all of society or even globally. Sometimes this works but at other times it fails and harms some sections of society or someone else from another culture. Belief systems claiming universal validity are called ideologies.
Conviction too often leads to concealment and dishonesty if this is necessary to support the ideology. This is seen as justified. Censorship and lies become accepted as a means of attaining objectives.
Bush, Blair and Howard persuaded the United Nations and the rest of us that Iraq was building nuclear weapons. As we now know, they did not have that information. It was all manufactured. Was this done to persuade themselves or to deliberately deceive us?
They were told and knew. Did they hear or were they incapable of doing so? People like Australia’s Andrew Wilkie blew the whistle.
There is the secret rendering and torturing of innocent people by the US government simply because it was suspected that they might be terrorists. A recent ABC Four Corners program exposed what happened
- Secrets, Politics and Torture: The ghosts of the CIA's controversial interrogation program. ABC Four Corners, 17 August 2015
As in South Africa under apartheid, censorship has been imposed on the treatment of asylum seekers by Australia. Anyone speaking out will go to prison. What will we learn one day when people can speak of their experiences?
Culturopathy: We don't like to talk about our failures and there is no simple name to help us do that. But pathological cultures and subcultures that cause harm are common. We know about them and usually read about them as isolated events. Because we don't have a name, we don't consider them collectively. We don't look at why they are occurring and the processes at work.
Because its a cultural phenomenon and its pathological (harmful) for sections of society (eg. the victims of human sacrifice in Mayan society), I have coined the term culturopathy. This describe cultures and subcultures that cause harm. Typically, they maintain their dominance by controlling and interpreting information. This enables them to influence the way others think and so get them to acquiesce to what is done to them. An ideology is at particular risk of becoming culturopathic.
My interest in cultures that go wrong is because I have lived and been in close contact with some of them. I am particularly interested in what happens when two contradictory cultures are forced together and occupy the same space. How is this resolved and how do the people involved behave? On the linked and other pages, I examine how this has resulted in a culturopathy in health and aged care in the USA and is probably happening in aged care in Australia.
The pages in this section examine the imposition of a new free market culture onto a sector (health and aged care) where there is already a long established culture that is very different and not compatible. It looks at how this works out and what happens. To understand how pervasive the problem of culturopathy in the marketplace is it also examines the multiple other failures that have been or are occurring in our society on a day to day basis by bringing them together in one place. This is to show that aged care is not unique but is part of a pervasive problem.
Market culture: A culture and a belief system, capitalism, built around trade and markets has worked reasonably well for society and proved to be more durable and useful than other ideologies - although it has not been without some problems. In the past market culture has been largely confined to the business of trade and the operations of markets in selling goods and services where customers were effective or unlikely to be harmed. Vulnerable sectors were handled differently.
Capitalism and capitalist democracy has depended on the balance of two different perspectives. The first was an emphasises on everyone's right to develop their lives and follow their economic interests. It claims that in doing so this will improve and grow society. It was directed at the individual and built around our "personal selves" using terms like "entrepreneurs" to promote its ideal performer.
In democracies the market was balanced by a culture that recongnised that citizenship also carried a responsibility for the rights and welfare of others. Citizens have a responsibility to society and its members. This responsibility takes precedence over personal rights that impact on others. In some sectors customers are at risk of being harmed because they are vulnerable to exploitation. In many professional services (eg health and aged care) capitalism was modified and controlled by cultural understandings that protected vulnerable citizens from exploitation. Strong subcultures developed that focused on this vulnerability and markets here were modified and controlled differently. This was supported and embraced by civil society.
In the 1970's a school of economics in Chicago in the USA led by economist Milton Friedman initiated a new more radical understanding of markets. They claimed that they were self-correcting and if left alone would sort themselves out. They could be applied to all sectors of society in the same way and would correct problems there. They claimed that they failed to work because of interference - particularly from government. Government involvement and regulation was always bad. Small government and the sale or contracting of government activities to the market became important goals.
Free markets became a universal good that was seen to be applicable to and to resolve problems in every sector of society. Its driving force was self-interest. Its driving forces, competition and efficiency, were seen as a universal good. The goodness was thought to reside in the process itself. The application of these processes was considered to be "reform" and because there was no doubt in the minds of the reformers any failures were because there were still things obstructing competition or efficiency and so inhibiting the free operation of the market. They needed removal. This liberated the market and it was called "liberalisation" in corporate jargon. In Australia we talk about economic rationalism. In politics we call it neoliberalism.
Community cultures: There is a broad cultural belief system in western culture going back to Hippocrates in ancient Greece and the Samaritan traditions of early Christianity. Belief systems within this tradition recognised our vulnerability, and our obligations to others and our society. Patterns of thinking, values, norms and ethical structures were developed to protect the vulnerable and encourage society to care for its members and act for the common good. We can see this as an expression of our obligations as a citizen - our social selves as contrasted with our self-interested selves.
This sort of culture comes from civil society and seeks to protect it and its members. It has been the dominant type of belief system in the various professions. In the professions, expertise and knowledge gives power and this renders others vulnerable. An additional level of trust and social responsibility was therefore required.
The churches and almost all not-for-profit organisations originate from within this cultural tradition. Civil society (seen as all of us when involved with the broad community) controlled the balance between self-interest and social responsibility. Because of its dominant position it could control markets and has in the past limited what they could do as well as where and how the market operated. Customers were from civil society and adopted its values. Democratic governments were beholden to civil society and legislation was passed that supported and protected their values so limiting the excesses of markets.
While this cultural heritage has bent and buckled before the winds of the successive ideologies to which we are so vulnerable, it has been durable and recovered.
What is happening: We humans are particularly susceptible to simplistic and plausible ideologies and when enough of us adopt them civil society is eroded. Civil society has survived ideology before and hopefully will again. Current ideology is more worrying because it has deliberately set out to remove the structures that protect civil society and to impose its belief and modes of operation on every sector and on everything that happens within civil society. They have been applied to sectors and activities that served society's interests rather than the self-interest of individuals.
If we look back, we see that society became busier and had less time for philanthropic activities. Providing care and services became too complex and costly. These responsibilities were trustingly handed to government who funded and/or operated them with taxes (public hospitals, education etc). The new neoliberal ideology required government to hand its services over to the market or contract them to the market to operate.
Some see this as a breach of trust. But it goes further than this. The market seems to bribe the parliamentarians to do what they require by donating to their election campaigns. It has gained a significant amount of control over the media and so been able to control the thinking of civil society, so limiting its ability to confront and control both politicians and markets - a critical factor in maintaining democracy.
So the market sector has come to dominate both the political and the civic sphere which are no longer able to adequately fulfill their roles in a balanced society. My concern here is not about markets or capitalism but about an ideology that is destroying the balanced society needed for capitalism to work effectively in a democracy.
A 2015 article in The Conversation expresses the same sentiments:
Can governments plan Australia’s future just by improving selected economic indicators? Will a focus on creating more jobs, cutting taxes and growing GDP be enough to ensure well-being?
A recent summit on future policy needs, auspiced by The Australian Financial Review and The Australian newspapers, accepted these items as setting its main direction.
Although the summit discussed more than the government’s slogans of growth, tax changes and jobs, it failed to address the need for setting a broader agenda that deals with social cohesion and the need for increasing trust in the political system.
The failure of markets
This belief seriously undervalues voters' capacities and beliefs. While an increasingly globalised market has led to increased GDP and net wealth over the past 30 years, all is not rosy.
The global financial crisis and current market sluggishness and irrationality show markets may not continue as main wealth creators. They face new risks from increasing inequality, climate change and domestic and international conflicts.
Australians need policies that rebuild community trust and reassure voters that their quality of life does require collective goodwill, not just growing GDP. Good governance depends on citizenship and leadership as well as policies that meet public good/common good and fairness tests.
Source: Social stability is the missing link underpinning economic growth The Conversation Sept 1, 2015
But I am writing about aged care here. The relevance is because of the impact of these developments on aged care.
Summary of the linked pages
The sliders below summarise the way these two different cultures interact and impact on health and aged care. They link to a more detailed analysis with examples.
How do people respond to conflicting cultures
The linked page expands on my interest in conflicting cultures. It examines what happens to people in a sector where a well-established culture exists but is now forced to operate and follow the dictates of a dominant culture imposed on it.
There are a range of responses to an imposed ideology, starting with conversion to the new belief system. These new converts rapidly become successful there, progressing to become leaders.
I examine the way psychological processes like selective perception, rationalisation and compartmentalisation enable them to adopt ideas that are poorly suited to the sector. Like most true believers they stigmatise their critics and can behave aggressively towards them.
Those unable to accommodate to the new mode of operation move elsewhere. Others lie low and may later convert. Some reluctantly tolerate. Some become alienated and lose motivation. A few see what is happening and are so disturbed by it that they destroy their careers by whistleblowing.
A fundamental conflict: In aged care the overwhelming community expectation is that those providing aged care will be trustworthy and that care will be their primary objective, but the market demands that profit becomes the primary objective.
The psychological process of compartmentalisation is particularly important for the converted. It enables them to embrace and believe in both of the contradictory belief systems and avoid the conflict. They genuinely believe when they promote their activities and speak to the public about their mission and their commitment to care. But when they are managing the business from the other compartment then the compartment with the ethic of care in it is kept closed.
I stress that this is not about evil people. Its about people who believe that they are doing good things and who have the best of intentions. But they are accommodating to a system that requires them to behave differently. The importance of doing good is so important for the sort of person they consider themselves to be, that they simply don't see or acknowledge that anything else is possible. They look past and don't recognise the harm they do because for believers that is impossible. Within a culturopathic culture the group reinforces this.
Learn more: Conflicting cultures
Culturopathy: A for-profit example
On this web page I give an example of a culturopathic health care company that embraced a pure free market approach to health care. It became spectacularly wealthy and was widely admired. It behaved in ways that were unbelievably bad but these were accepted and admired by the business community, by regulators and by the insurers who paid them all that money.
Vast numbers of people, but particularly children were needlessly admitted to hospital and many were harmed. The company, its managers and its staff had no doubts about what they were doing and that they were leaders in providing care. They were proud of it and boasted of their practices. Many other companies adopted the same practices in order to compete. It was industry wide.
Even though it was all exposed and the company paid a large fine they were simply unable to accept that what they were doing was wrong. They blamed the press and thought this had influenced the court. Ten years later, the same thing happened in another section of their business. By then their renewed profitability had once again turned them into marketplace heroes. Critics who tried to intervene were ridiculed and swept aside.
In the first scandal it was a policeman who exposed what was happening. He realised that a teenager was being kidnapped and taken to hospital, not because he was ill but because he was profitable. In the second it was a patient, a priest, who realised that he was only one example of widespread unnecessary surgery driven by profit. He went to the FBI and they investigated.
This is an extreme example but there is so much material available that the whole process is laid bare. To understand why and how it all happens read the linked page. There is much more there. This example is representative of what happened in multiple other health and aged care companies. And of course there were and still are less confronting but also dysfunctional things happening across the entire health and aged care sectors as marketplace thinking has replaced community values as the driving force in the sector.
The page goes on to explain that this is not about this company or evil people. Its about us, all of us and how we behave. If we had been there most of us would have behaved similarly. I go on to explain why I chose culturopathy over other names to apply to this disturbing but very human pattern of behaviour. Finally, there are some more complex ideas about the way that we have to deceive ourselves in order to maintain an authentic identity while being part of a culturopathy - how we cope with situations that require us to harm others.
Learn more: For-profit example
Failed markets and culturopathy
Culturopathy: On the previous linked page I explored the nature of culturopathy in the free market and the way it is driven by competition for profit. I tried to explain the psychological and social adaptations that enables participants in this system to exploit any vulnerability in the system when this gives them a competitive advantage. My particular concern is the exploitation of human vulnerability and weakness although this is not the only thing exploited. Strategies are developed that allow the people involved to identify with or in some way justify what they need to do to succeed. To do so they usually find some way of persuading or deceiving themselves.
A very common problem: I am arguing that aged care is not unique. It is part of a society dominated by a culturopathic culture that exploits any weakness it finds. This is common, occurs every day and is characterised by periodic red flag exposures of harm. In the flood of information we get each comes to us as an isolated event. We see this as the failure of other individuals rather than of our society - of ourselves as members of that society.
Recognising the problem: But we do the things we do because of the way we conceive them. It is only when we bring all this (from multiple different sectors) together that we see its extent and the common patterns of thinking and behaviour. We can recognise it as a major societal issue, can identify where we have gone wrong and then start looking critically at the belief systems that underpins the way our society operates. That is the first, essential and for many most difficult step in addressing the issues.
Confronting doubters: To ensure that there is no doubt about the extent of the problem I have assembled multiple examples outside health and aged care where, in most instances, vulnerable people have been exploited and harmed over the last few years. I have looked at a few in more depth in order to illustrate the similarities and the patterns of behaviour. I don’t expect many to read it all and follow the multiple links. The object of this page is to confront and persuade the doubters who don’t believe this happens and can’t accept that we are all at risk of behaving like this. They may need to follow the links.
It sits at the heart of society: In many instances it is the most trusted institutions (Wall Street in the USA and the banks in Australia) and the business leaders that we look up to in the marketplace that are most vulnerable to culturopathy. This is not surprising because they are the true believers who have pursued free market policies in the most focused way. They have become acknowledged leaders. They have invested so much of their lives and their identity in this and in the self-evident legitimacy of the ideas that underpin it. They will have the most difficulty in confronting their beliefs when things go wrong. Also very worrying is the time it takes to expose the failures that are occurring and the harm done, sometimes 10 to 20 years.
Putting it behind you: The bad publicity associated with red flag events soon passes and the companies involved appoint new distinguished and successful leaders who think the same way. They regain their credibility and status but do not change their thinking. They are at risk of continuing the same practices more carefully because they would not be successful without this. If they don’t do as well as they once did in the marketplace then they readily relapse a few years later and do it all over again.
The community probably easily forgets. These people and institutions are pillars of society and we shrink from things that confront us. Our society has become so frenetic and overloaded with information that we don’t see the multiple red flags together so fail to recognise the trends.
This is facilitated by the credibility and confidence of the new leaders and the endless positive marketing. Market and the politicians they support don’t or won’t see and acknowledge the basic flaws in the system because their thinking is paralysed.
The examples given: On the linked page I first examine a price fixing scandal in Australia and a massive Wall street multinational, one of many involved in recurrent scandals. I look closely at the Commonwealth Bank and at 7-Eleven as both provide good examples of culturopathic behaviour.
The page also gives brief outlines and links to multiple other examples from multiple sectors to illustrate the extent of the problem in our society. With the exception of the Wall Street example they come from Australia.
It is difficult not to conclude that when there are weaknesses that can be exploited then sooner or later someone will. When they get a competitive advantage then others will follow. Competitive pressures can make this an imperative. Many are harmed.
The way they think: In almost every instance we find a wide difference in perspective - in understanding and accepting what is happening. Management understand it very differently to those who have been harmed and also to independent outsiders. This results in management denying, distrusting and attacking critics, minimising and avoiding responsibility. They try to shift the blame, in one example to franchisees who had been put in an impossible position. They even shift it to those they have harmed.
In two of the examples management have turned on those they have defrauded when they claimed compensation. They have accused them of trying to defraud the companies when they have sought compensation. This can be seen as an expression of their denial, disbelief and inability to accept what they have done. In a later section, Widely Contrasting Views, I will look at this sort of behaviour in aged care.
Data: Another characteristic is a failure to collect information, to properly examine available information or to evaluate it correctly. To do so would be revealing. Because they know but don't acknowledge what they know they avoid doing anything that would force them to confront the things they dare not acknowledge. This has characterised aged care and I will look at that too.
Relevance to aged care: The linked page concludes by asking how likely it is that aged care, a very vulnerable sector, has successfully escaped when every other vulnerable sector has not. I think there is enough information to show that it has not.
Learn more: Failed markets and culturopathy
Contracting government services to the market
Government services are provided to vulnerable members of society and paid for by government (taxpayer). These services are particularly at risk when they are contracted to the marketplace because those served have no leverage and are so powerless. These examples are most relevant to aged care because most of the payment and also the oversight and regulation are provided by government. The aged are among the most vulnerable and trusting so are poorly equipped to survive in a ruthless free market.
The linked page examines two examples
A. Job services: This is the service provided to help the unemployed find jobs. Previously provided by government and not for profit community organisations it was contracted to the free market by the Howard government in the 1990s. Job seekers were harmed rather than helped as multinational and local for-profits, and even some not-for-profits competed to extract as much money from government at the least cost.
B. Vocational training: The same thing happened when vocational training largely funded by government and provided through TAFEs was turned into a competitive market. Vast numbers of innocent people were conned into signing on to courses which they were not capable of doing. They borrowed the money from government. Vast profits were made as many were given shonky and inadequate training in shortened courses and others dropped out. A past federal minister of education was on the board of one of the principle offenders.
Many of the inadequately trained were level III and IV aged care nurses. The government was forced to withdraw thousands of diplomas throwing many including some aged care nurses out of work.
Both the job search and vocational sectors were set up to be rorted and not surprisingly they were.
Aged Care: Aged care is of course another community service to vulnerable people that is largely paid for and regulated by government. The introduction of Consumer Directed Care is intended to make the sector conform more closely to a free market using the mantra of offering choices. Home care, traditionally a community provided service, is leading the way. People here are more isolated and so more vulnerable.
Is aged care being set up to be rorted? Have they learned anything from past experience?
Learn more: Contracting government services to the market
Response of the not-for-profits
On a page in the previous marketplace section I described some of the strategies not-for-profits are adopting in an attempt to compete with for-profits and not be decimated by for-profit competitors.
On the linked page I look at the way not-for-profit operators providing care respond to having to operate in this environment - what they are saying and thinking. Doctors and not-for-profits face the same problem. They both come from sectors where placing the patient or frail person first is a core and unalterable belief. But to succeed in this market they must compromise.
Compartmentalisation is therefore a very important process for them. It allows them to do what they have to do to survive but "not know" that they are doing that. If you don't look or don't acknowledge then you don't have to confront. Their responses to situations that they find themselves in can come from one or other compartment.
The linked page looks at what they are saying. It illustrates the spread of opinion from those who have converted and see no difference between for-profit and not-for-profit operators, to those who feel that the sense of mission is critically important and that it is essential for success.
My assessment is that they are responding by accepting the situation and accommodating as best they can. But at a deep level they are confused and conflicted. They do not know who they are, what they are doing here and where they are going. They are losing or have lost their close links to the community from which they originated as well as their mission which no longer has real value in this new environment.
Learn more: Dilemma for not-for-profits
Driving cultural change
Young enthusiastic business trained consultants in smart suits are running seminars in which they stress the risks for the not-for-profit operators if they don't change and behave like for-profits. They are acting as advisers helping them to transform, to partner with others (usually a for-profit) or to sell to a company that can make money.
If managers are not performing financially and have "lost the will to win" then they should be replaced. One wonders what winning could possibly have to do with providing care to the weak and frail. Its a whole new world that they are being told to adopt and it really has so little to do with why they exist at all. These consultants are offering their service to advise the not-for-profits what to do.
Consultants and managers are also targeting councils who operate their own services in the community, either home care or nursing homes. With their advice the councils are selling these facilities and services to for-profit operators to run.
There is considerable anger within these communities. In many instances the services and the buildings have been erected by the local communities, through their own fund raising activities, operated by them and then later given to the local council in trust. They feel betrayed, but the councils are taking financial advice and lot listening to their communities.
At the same time, the government has changed the funding structure for aged care and its regulation in ways that make it more difficult for many not-for-profits. They are encouraging this process and helping the market to consolidate. At the same time they are claiming to be introducing policies directed at supporting small business - but aged care does not fit into that model.
The Centre for Welfare Reform in the UK has written about this sort of thing. They describe it as a "hollowing out of communities". Instead of building local expertise, local involvement and social capital the services are contracted to a distant operator who does not understand the local situation and may provide an inferior service. Local communities lose skills, jobs and knowledge. They are impoverished by the process.
The Centre believes that by trusting local communities, building expertise and using them a superior level of care and quality of life is provided. Communities are built up and engaged as active citizens rather than undermined and degraded. This is what the community aged care hub is also attempting to achieve. It aims to place the community at the centre of the aged care process.
In the last slider on the linked page, I look at INTFPCompanyB a company that talks and speaks like a not-for-profit but behaves like a for-profit. On its web site it does not use the terms for-profit or not-for-profit and when asked directly it dodges the question.
It's parent in the UK is a provident association limited by guarantee and it claims its focus is on benefitting its members and meeting its objectives. It is far from clear who its members are. It may once have behaved as its web site claims. After a new CEO was appointed in 2003/4 it adopted a much more aggressive global growth strategy becoming a major provider of insurance, hospital and aged care across the world. Its objective is clearly growth. In Australia it is classified as for-profit and that is the way it operates.
Learn more: Driving cultural change