In 1993 I met with and discussed internal corporate documents with a taciturn US whistleblower. A major country-wide US healthcare fraud involving NME, a very successful US hospital corporation providing psychiatric and substance abuse services, had been exposed. The whistleblower had spoken out and given evidence. Most competing companies in the psychiatric and drug abuse hospital sectors had copied their successful practices and were now also being investigated.

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A for-profit example

The problem: Large numbers of vulnerable patients had been harmed. These included hundreds of normal children whose parents had been persuaded to admit them to psychiatric hospitals, often for periods of 3 to 6 months. Here they received vast amounts of very profitable but unnecessary “treatments” for which their insurers paid. Small children and teenagers were badly treated and harmed.

"This is how they think": In the documents I asked the whistleblower about, staff were reporting on their successful money-making activities. They boasted enthusiastically at a company conference of very successful but totally unethical practices that exploited parents and other anxious peoples’ vulnerability. They clearly had no idea they were doing anything wrong and were boasting of their achievements. My contact just smiled. Then he put it very simply. He said "that is how they think".

How it happened: Other documents revealed the policies driving these practices, the command structure from the directors through the levels of management, and the "explanations" used to explain why they were so beneficial. When all logical explanations failed, the reason was that "it was the American way". They saw this purely as the business of making money.

They explained that if they made money from it then the care must be good - otherwise customers would not come. Other considerations, when they arose, were explained away. Profitably, but not care was tracked down through all levels of the system. Managers were well paid, fired if they failed to perform, praised, and given bonuses of up to 50% of salary when they did. There was enormous enthusiasm.

More documents showed that the founding directors were as surprised as anyone when it all fell apart. They simply did not look at it in ways that would have revealed what was obvious to many others. No one in the organisation had the power to force them to confront what they were doing, and the wider community did not know.

It was an outsider, a policeman, who finally blew it apart. He realised that a psychiatric medical certificate was simply a means of kidnapping a teenager. He believed the parents of a kidnapped teenager, rather than the credible hospital staff.

Responses: Even after a criminal conviction executives in the company refused to accept that their very successful practices were flawed. They believed they were victims of an unfounded media-driven beat-up. What they had done is what managers did in many other businesses, and in their minds health care was no different.

Other companies continued to do the same or similar things in other health care sectors. Health care fraud became the most common fraud prosecuted by the FBI in the USA. Retribution did act as an effective deterrent in some situations but overall its impact was marginal.

Ten years later, when the next generation of managers were in control of this company and regulators were no longer looking over their shoulders, this company was once again the profitable darling of the share market. In 2002 a second scandal revealed that they had done it all over again.

Many hundreds of unsuspecting patients underwent unnecessary and harmful major surgery on their hearts. Some were simply health conscious and had been unwise enough to attend "heart screening" programs the company ran. This time it was another outsider, a priest who put two and two together, obtained alternate opinion and took it to the FBI.

A core problem denied: During this time this company was the second or third largest corporate hospital operator in the USA. It was a major political donor and there was a revolving door with government. Robert (Bob) Kerrey was a long-time board member. He was a decorated Vietnam War Hero, had been Governor of Nebraska, a US Senator, and for a time a favourite as democratic candidate for president until defeated by Bill Clinton, and by Al Gore for vice-president. He was succeeded on the board by Jeb Bush, a past state governor in Florida and brother of US president George Bush Jnr.

This company was not a peripheral rogue or a rare exception. It had many thousands of employees. It was one of the big companies driving the corporate changes to health care at the heart of the US health care system. It was a leader, and its criminal conviction did not change that. Few in the USA challenged the way in which economic rationalist thinking had been applied in health. Criticism might have been rational but in the USA it was not credible.

Other companies poached this company's profit-making, trained managers and emulated its practices in order to compete successfully. The company operated hospitals in Australia from 1991 to 1996. In spite of its track record it was welcomed by business and by politicians of both parties at a time when its conduct was headline news across the USA.

A flow on to aged care: Until the end of the 1980s this company had a large aged care subsidiary in the USA called Hillhaven (called "Unsafe haven" by nurses).  It was run by the same executives. The managers it trained moved to executive positions in other aged care companies or started their own. Many of these companies were soon embroiled in fraud and the misuse of the elderly. One of these trainees had founded his own very successful company, Sun Healthcare. His company bought small rehabilitation hospitals in Australia in 1997, intending to enter aged care and make major changes to our system. He had the ear of politicians and both the federal ministers for health and aged care started promoting his solutions to "our problems".

This aged care company was soon accused of fraud in the USA and of neglecting unprofitable frail residents. Instead, it over-serviced the profitable rehabilitation patients, that it was admitting to its US nursing homes. Competitors had jumped onto the gravy train and the US government was paying. The US government finally stepped in to stop it. Those companies that had adopted this practice became bankrupt. It was a narrow escape for Australia. For years after he had been dumped, the company founder was still promoting himself as a world authority on aged care with solutions for others problems. Some still believed him.

The same thing had happened successively in psychiatry, cardiology and rehabilitation/aged care, yet no one in the USA, or in Australia, had seriously asked why or how.

Source: Information about the hospital company Tenet Healthcare (previously called National Medical Enterprises or NME) is here. Information about the nursing home company Sun Healthcare founded by an executive Andrew Turner trained by NME is here.

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How it all happened

There were warnings: This is the most confronting of many similar examples I could use. It is not that the public and politicians were not warned of what was likely to happen. US doctors wrote clearly and debated publicly on television during the 1980s. They stressed the problems and warned. They won the logical argument but attacks on them by government had damaged their credibility. The companies were already making vast sums of money and the share market was ecstatic. The juggernaut ignored the arguments and rolled on.

Building worlds: We humans have an enormous capacity for building a world of ideas that suits us and ignoring everything that does not or is contradictory. It has happened in many societies over the centuries. Cultural groups with simple convictions dominate and take over from those who find the world more complicated and uncertain. The simpletons become credible and this is reinforced by success in one or more areas. Action requires confidence and certainty and this has evolutionary advantages.

Destroying conflicting worlds: When there is a massive paradigm shift, as was imposed on health and aged care, then the new ways of thinking must be promoted against the old, which are consequently seen as harmful and undesirable. They are denigrated and eliminated, replaced with the new ideas. Doctors and their concerns were not profitable for the company and the role of clinicians was downplayed. The following quotes are from internal documents from the US company described above and from evidence at a government inquiry into what happened to psychiatry across the country.

... I concur with your assessment of the current associate administrator; that he is too clinical and not a decision maker. Please proceed with his 'resignation' ..."

"I concur with your decisive action with regard to the 'back door problem:' " (Note that the back door problem was when clinicians discharged profitable patients who no longer needed treatment before their insurance cover expired)

Source: Instructions to hospital manager from Corporate documents tabled in a court action against Tenet/NME

The provision of mental health care, especially as it relates to the psychiatric hospital industry, has largely changed from what was once a professional and caring environment and an honourable part of the medical world, to one that is based on commercialism and profit. The changes that have developed over the past decade are very pervasive, deeply entrenched, and have occurred across the entire United States"

"What happened here -- this is what I was asked to do, to sell my MD degree which gives me admitting power to a hospital. Once that's done, the sky is the limit. If you as you said, look the other way, you'll become enormously wealthy and the treatment is taken over by the non-medical people, absolutely non-medical with no medical training at all." (Doctors were required to hand over their patients to money-making treatment programs. A document "Winning Programs" instructed managers how to squeeze as much profitable treatment into the program to maximise income during the insurance period.)

Source: Evidence US House of Representatives Inquiry entitled "Profits of Misery" April 1992 Dr Charles Arnold

Reflect on what is happening in aged care in Australia. Much of the care of the elderly is now carried out by nurse aids with almost "no medical training at all" and with minimal qualified nursing supervision.

How much of this is really about profitability - the profits needed for shareholders and growth? The answer is - we simply don't know because we are denied the information.

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It was focused on the insured

In this US company, the focus on clinical considerations was reduced to the extent that care became a word only. The clinical focus was completely replaced by business objectives. Treatment and care had no connection with reality. They were simply assumed to be there because the words were. Because care was good for you more care was better. It did not matter what sort of care.

Instead, the focus turned to admissions and to keeping people in hospital for the duration of their insurance. Whether they needed to be in hospital or needed care was irrelevant. A collection of illogical rationalisations, clothed in words with positive associations that gave them legitimacy, were trotted out as unchallengeable truths. Belief in what they were doing was paramount.

Television advertisements, and even books were designed to stir up community anxiety about mental illness. Bounty hunters, paid $2,000 per head on a bed, scoured the USA and even Canada persuading people they needed hospital care. The remuneration of people running community programs was based on their "conversion rates" - the number of insured inquirers converted to admissions.

Others were employed specifically to persuade patients they needed to stay in hospital until their insurance expired when they were cured. If you were not insured you escaped. Vast profits were made and staff who were "team players" were wildly enthusiastic. Non-players were ejected.

This is a sector where marketing and selling your medical wares had been prohibited for 2000 years. Doctors could put up a plaque with their name, degrees and areas of expertise - but no more!

We might compare this denigration of "obsolete" clinical ideas with the Australian politicians who told Dr Mykyta (the geriatrician I quoted on the first page I wrote on the Aged Care Crisis web site) that health and aged care was too important to be left to doctors. For them, it was obvious that all this old-fashioned nonsense needed to be replaced with their ideological market solution, which had been shown to work elsewhere! Restricting advertising was anti-competitive and medicine should operate like any other business.

The politicians Dr Mykyta would have been talking to were those who brought in the current system in 1997 and are still trying to make it work. They were and may still be strongly influenced by the system of beliefs promoted by Reagan's adviser Joseph Califano, who sold the illusion that doctors rather than commercial pressures (which were sacrosanct) were the main problem in the 1980s' US Health care system. The consequences are apparent in what happened in NME and multiple other companies.

... There was a tremendous amount of pressure put on everybody within the PIA (Subsidiary of Tenet/NME) network that we had to meet or exceed our budgets. There was no question in anybody's mind about that".

"All of the marketing and referral network policies and procedures came from a corporate level."

"The success or failure of the referral system was more important than the success or failure of the treatment of the patients"

Source: Evidence US House of Representatives Inquiry entitled "Profits of Misery" April 1992 Mr Russ Durrett - Tenet/NME hospital administrator.

"We've got people out there --- and we're going to hire another one in marketing that does nothing but beat the bushes and finds the patients and sends them to the hospital"

Source: Transcript of Tape recording of meeting with Tenet/NME administrator by Dr Arnold. Evidence Court action in Texas 1991

"- - - I want them to be able to sell the benefits of the free evaluation - - - regularly review and discuss each others' conversion rates - - - to be sure that they don't have professional/personal issues or biases that can impede their intake performance."

Source: Internal Tenet/NME corporate document setting out "golden rules" for administrators in charge of untrained staff doing the evaluation of people enticed by a help line to come for a free mental evaluation.

In 2004, Bartlett and Steele, two award winning New York Times journalists published a landmark analysis of health care in the USA titled "Critical Condition: How Health Care in America Became Big Business & Bad Medicine". They accurately identified the issues and the problems across the entire sector but could not come up with a workable solution.

I have written about their findings. The US Health system they describe in this book is a remarkable illustration of how what I am going to call culturopathy, becomes established, engulfs large sectors of society, harms citizens but then becomes intractable and almost impossible to change.

In markets: In our market-based society in the USA and Australia something similar, if not quite as confronting, has occurred in almost every one of those sectors where the customers are vulnerable for one or other reason. They have been exploited and harmed. Legal restraints have not prevented this. Regulation has had only a limited ability to stop the worst excesses.

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Where does the responsibility lie?

Are they evil?: So, are these cynical, evil, grasping people or simply true believers in an economic cult? Many seem simply to be people who don't see what they are doing and cannot understand why something so successful can be wrong. Many thousands embrace an idea and follow it. What they believe in seems more real and more important to them than what they see around them. But maybe truly "evil people" do exist and seize the opportunity. Maybe its somewhere in between. My impression is that the deliberately evil people are there but are exceptions.

It's all of us: Some researchers find sociopathic traits in many of the leaders coining the term successful sociopaths, and they are undoubtedly there. But sociopaths are individuals and we are talking about many thousands and sometimes millions, even a whole nation. So its time we looked more closely and realised that its just us, all of us, and that if we were in their shoes many of us would do the same things. Its how we humans behave.

The pressures to be someone are very strong and this is why we may choose not to know or to look the other way when we are building our lives in a culturopathy. Stuart Rees was probably not thinking along those lines when he wrote the bit below.

"(Managers) - - - waiting in the wings for the call to demonstrate their toughness and efficiency, their willingness to disparage old professional practices and traditions in the interests of a new corporatism."

"Associated with this promotion and educational expansion is a corporate language and accompanying attitudes. These are the outcomes of preoccupation with management as the panacea for governments and organisations."

Source: Source: Stuart Rees in "The Fraud and the Fiction" from "The Human Costs of Managerialism" Pluto Press 1995 page 16

When larger groups adopt the ideas and the language and build their lives using them then they will consciously seek to recruit others, particularly those who are a part of the group or wider society. As the numbers grow society can then be restrucctured using these ideas.  Instead of using knowledge of the social sciences to understand what is happening and address the problem, social groups too often use the insights gained from the social sciences to implant and promote the ideas they believe in.

" - - - - the all inclusive claims of "culture management" with its emphasis on changing the culture of an organisation by paying attention to language, symbolism and ritual (Peters and Waterman 1982)"

Source: Stuart Rees in "The Fraud and the Fiction" from "The Human Costs of Managerialism" Pluto Press 1995 page 17

Why its all of us: Each of us arrives in the world with a variety of different attributes and potentials. As existentialist philosophers have explained we have no choice but to build our lives in the situations that are available to us and try to find one where our particular potential can be realised.

We have no choice and where society does not provide us with somewhere where our particular potential can be realised we can become alienated and reject society. We may even build a life that seeks to destroy the society that has excluded us - and develop justifications for this.

Where does that argument lead? As believers in freedom and democracy wanting to provide opportunities we can argue that an essentIal function of a broad society seeking to use all its human potential would be to create a wide variety of contexts.  Very different people with different potentials could realise their potential and make their contribution to our human endeavour.

We need to ask ourselves whether our society is actually doing that or whether it is limiting the sort of contexts where people can succeed and is wasting much of our human potential. We seem to be offering a form of individual freedom where anything is OK and innovation is king - but only if it is congruent with what our thought leaders have decided they want.

Not everyone is competitive and so intent on self. They can become alienated by a society that is so focused on self actualisation through competition and markets.  Many are analytic and self directed and the pressures created in the market can constrain their efforts.  Others are reflective and have the potential to structure their lives in very different ways and contribute intellectually.

When society fails to offer options people will develop and build a set of ideas and even a lexicon of words to justify what they decide they want to do there. They are likely to become enthusiastic believers, whether this is a new religion or a way of running the world.  Sometimes this will be beneficial and open up new opportunities. At other times it will be dysfunctional and culturopathic.

It is here that the more reflective and analytical members of a broad civil society might contribute most by identifying aberant ideas and debating them - guiding society so that it does not develop into another culturopathic movement.  But as is well illustrated by economic rationalism these same reflective people, when locked behind the doors of think tanks with like minded people, can develop aberant ideas and become very influential. Reinforcing one another they can come to believe implicitly in a set of ideas, ignore their critics and gain the ear of leaders. 

Would it have been different if neoliberal/economic rationalist ideas had been widely debated at an early stage in the 1970s?  If this had been an Athenian style democracy where a reflective civil society was actively engaged in the affairs of the nation - one where power rested with civil society and not markets.  Would the sensible arguments of people like Druker, Kuttner and Relman have been discussed and considered?  Their arguments were sound but, without an informed and active civil society capable of listening and analysing, markets imposed.  Their economic success made it a fait accompli.

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Culturopathy - a name for the problem

One of the difficulties in writing about this phenomenon is that we have not had a catchy name for it. We need a quick tag that brings up an image. We need a term we can use to refer to "it", "them" or even to "us".

A cult is embraced with similar fervour, but is hardly appropriate as our name. What we are looking at tends to become mainstream. A cult is usually about a minor religion. The business world uses the term "cultural silos" to refer to groups within the organisation whose control of their own data, without sharing that with others, obstructs and interferes with corporate success.  We might apply that to some think tanks but not to wider society.

There are similarities but in the wider society aberrant groups are far more ambitious and more often seek and gain power. Silos does not really describe them. The groups I am interested in tend to adopt an ideology and often apply the ideological beliefs in an inappropriate way in order to further their own ambitions.  On other pages I will look at why we are so vulnerable to simple ideas and convert them into ideologies.

Those groups I am talking about get their way by controlling and interpreting information their way. They reveal only the information needed to support their arguments and hide what embarrasses them. All seek to protect their beliefs and actions from scrutiny and criticism, and avoid confronting logical arguments. They use selective perception, rationalization, compartmentalization, and labelling to validate their belief and demolish critics. They turn to believers for confirmation and avoid constructive engagement with critics. Their aggressive assertiveness and attacks on the messenger make them difficult to challenge.

If sociopaths are individuals who create their own reality without insight into or empathy for the consequences of their actions, then Cultures that do the same might be called "culturopaths". Its a horrible word but I can't find a simpler word that is more suitable so I am going to use it.

Aged care is not unique. If not already a victim of culturopathy, then it is a potential victim of something that has been happening in society for centuries. Culturopathy has become a major problem in several sections of our capitalist society.

My view is that aged care is well down this path. The suggested Community Aged Care Hub will makes it much more difficult for "culturopathic" cultures to develop and when they do has, as a last resort, the power to eject them. To prosper, culturopathies must control information and be able to put a distance between themselves and the real world. The proposed hub would prevent this from happening.

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Wilfull blindness, self-deception (Bad Faith) and culturopathy

On the previous Conflicting cultures web page when discussing “compartmentalisation” I wrote:

My impression is that compartmentalisation is often accompanied by mentally detaching the paradigms used from the real world that they should represent, - - - .

You may find it a bit difficult to understand how, even if you put your humanitarian views into a separate compartment, you could when using that compartment fail to notice that both you and those around you are actually harming people and feeling mortified and guilty when you lie. Yet these people so obviously are not lying.

That is a problem that others have looked at. Philosophers have described a way of understanding how we detach ourselves from the world around us by deceiving ourselves.

Explanation: That we humans somehow find ways of ignoring what we don’t want to know about is beyond dispute. But how do we explain and understand it. It is one of those difficult to understand aspects of our humanity, one where we struggle to find concepts that adequately embrace what is happening.

Willful Blindness: Margaret Heffernan has taken the legal term “willful blindness” and use that to describe this phenomenon. Essentially the word implies that we deliberately choose to not see what it is in front of us and that certainly embraces much of what we see. In her book Heffernan explores the psychological studies that have been done to illustrate how we do this. She gives multiple examples.  I am not sure that she really exlains why it happens convincingly but it is a convenient way of exposing the problem.

Margaret Heffernan examines the phenomenon of willful blindness, exploring the reasons that individuals and groups are blind to impending personal tragedies, corporate collapses, engineering failures-even crimes against humanity.

Source: Willful Blindness: Why We Ignore the Obvious at Our Peril

Heffernan gives a short and incisive talk about this using one example on Youtube which is worth watching. We are all aware of this sort of thing happening but somehow we never think of ourselves as being part of this yet one way or another we all are.

What is said and what cannot be said:  In her doctoral thesis Dr Axxxxx Dx Bxxxxx in Chapter 6 explores these issues by focusing on the discourses surrounding aged care in nursing homes particularly what is said and what is not said - what I have called the elephants in the room. This is essentially an approach to the construction of knowledge which looks at the consequences of ignoring what we don’t want to know and what others who see things differently are trying to tell us. These are the things that simply cannot be said publicly and which are therefore so challenging when finally revealed!  We can understand why the industry felt so threatened and so aggressively attacked her (see the 2nd slider on the page Is this Culturopathy?).

I recall studies in the 1970s looking at the way people interacted to set the parameters of discourse before they commenced the interaction. It was the more powerful who set the limits of discussion and the paradigms used - what could be said and what was not legitimate. I was interested in how the parameters of discourse were set out in everyday interaction between the different ethnic and political groups in South Africa under apartheid to protect the system and maintain social stability.  The credible and acceptable paradigms were those of the dominant participants.

The academic leaders of the Black Consciousness movement were acutely aware of the way in which this impacted on the consciousness (the way they understood) of the black population many of whom at one time saw the racial structure as simply the way things were and opposed destabilising changes. The supported their oppressors.  This enabled a small minority to dominate a majority. The strategy of black empowerment was directed to addressing this by creating paradigms of understanding through initial black with black discourse as a preliminary step to informed debate. This allowed them to develop frames of understanding behind which they could unite and mount a strong position.  The white groups (like the aged care industry), even those who supported a democratic society, saw this as militancy.  Their leader intent on a peaceful solution was killed by the police.

Theoretical perspective: Dx Bxxxx bases her research on the work and insights of the philosopher Foucault. She uses his insights in Chapters 2 and 3, in which she describes the history of our aged care system. How we got what we have got and not what we might have - or perhaps should have got. She describes Foucault's  approach in Chapter 1. On page 13 and 14 she says

The incorporation of power is able to render the individual and collective bodies under control through a process of making them docile, asleep, silenced, and disciplined to the dominant discourse - thereby governing their acts, attitudes, and modes of everyday behaviour and practice. The subject as such, ‘becomes the object of highly complex systems of manipulation and conditioning’ and the concept is postulated of ‘the discipline of the body and the control of the population’ for the benefit of civilization as a whole.

He (Foucault) describes the ‘infrapower’ or ‘the whole set of little powers of little institutions’ that makes possible the political and economic power that is exerted on persons through the dominating discourses.

 If we look at the way the debate has been conducted by the neoliberal movement we can see the way their assertiveness has set the parameters for legitimate discussion with the Australian public. It is what was not said that mattered and the plight of the aged can be seen as a consequence.  If we examine the interaction between residents and their families with providers, between the complaints system and complainant or between the community and politicians we can see the same things happening.  This approach adds to what Heffernan and Sartre are saying by adding a social dimension to the process.

The proposed Community Aged Care Hub is intended to counter this in the same way as the black consciousness movement did - by creating a venue of discourse in the community which will enable them to define and build their own parameters and then insist that they be adopted in discourse with the industry and government.

Bad Faith: Philosopher Jean Paul Sartre wrote about the way we delude ourselves much earlier in the 20th century. He challenged the prevailing idea of the subconscious as an explanation of human behaviour. He argued instead that we lie to ourselves but in a complicated way. This is complex philosophy and not easy to follow but his conclusions are clear. In his discussion of identity he takes the idea of willful blindness to a deeper level where it is less of a conscious decision because the basic lie is within consciousness itself.  He considers that we all do this at some stage almost involuntarily.  We have to guard against it if we wish to be authentic.

He argues that it is the existential forces, which we all face as we struggle to define and embrace an identity for ourselves, that drive us to this. It is what we do in order to escape the angst of being authentic.

As humans we are under extreme pressure to become someone and have an identity. There is an existential imperative for us to have an identity within the context within which we live and to believe in that identity ourselves if we are to be effective there.  Sartre described the way in which we deceive ourselves so that we can be who we need to be.  His idea has been translated into English as “bad faith”.  Sarte sees this as something that many if not most of us do and do regularly, some in an ongoing manner.

Essentially it is the idea that people deceive themselves in order to claim an identity because that identity is essential for them. They continue to deceive themselves to maintain that identity. So they know but do not admit that they know.

Forward: Bad faith is the technical term coined by - - - Jean-Paul Sartre which (is) the state of human inauthenticity where one attempts to flee from freedom, responsibility and anguish. It is a paradoxical and therefore ultimately schizophrenic attempt at self-deception. To live in good faith means to strive for authenticity and to continually be aware of the tendency to slip into bad faith.

Sartre wrote

The situation cannot be the same for bad faith if this, as we have said, is indeed a lie to oneself. To be sure, the one who practices bad faith is hiding a displeasing truth or presenting as truth a pleasing untruth. Bad faith then has in appearance the structure of falsehood. Only what changes everything is the fact that in bad faith it is from myself that I am hiding the truth. Thus the duality of the deceiver and the deceived does not exist here. Bad faith on the contrary implies in essence the unity of a single consciousness.

Even though the existence of bad faith is very precarious, and though it belongs to the kind of psychic structures which we might call "metastable," it presents nonetheless an autonomous and durable form. It can even be the normal aspect of life for a very great number of people. A person can live in bad faith, which does not mean that he does not have abrupt awakenings to cynicism or to good faith, but which implies a constant and particular style of life.

In bad faith there is no cynical lie nor knowing preparation for deceitful concepts. But the first act of bad faith is to flee what it can not flee, to flee what it is.

If bad faith is possible, it is because it is an immediate, permanent threat to every project of the human being; it is because consciousness conceals in its being a permanent risk of bad faith.

Source: Bad Faith: An Essay by Jean-Paul Sartre Philosophy magazine

So if you are required to be a nursing home manager and be all of those things that a good nursing home manager is supposed to be. But in practice what you are required to do is very different and results in people being harmed. Bad faith is really the only way out of that for you - a kind of frail and vulnerable schizophrenic mental state that has to be maintained so that you are the person you have to be, and not the person who allows others to be harmed, the person you know you really are but your consciousness will not acknowledge.

On these pages I often talk about people seeing but not acknowledging to themselves and that is very closely related to what Sartre is saying.

All of these concepts are of course an attempt to grasp parts of our human complexity and so help us to understand the strange animal that we are and the things that we do individually and as a society.

Despite its complexity and the difficulty of coming to grips with it Wilfull blindness and/or Bad Faith are probably an integral part of every culturopathy. People simply cannot otherwise maintain an apparently authentic identity and present themselves publicly as such when they are in a situation where what they are doing is harmful. We are not good liars and we expose ourselves if we deliberately lie about our identity. But if we first lie to ourselves then we can present that identity as authentic because we now see it as such.   This and the simpler idea of compartmentalisation provide a framework within which the strange but very common world of culturopathy can be understood.

KISS (Keep it simple stupid):  A simpler way of coming at this is simply to look at evolution, a ruthless process driven by competition, one that selects for those best able to survive in the context within which that species finds itself - the survival of the fittest for that situation.  Too often though evolution takes species down blind alleys and they do not survive.  Mankind has been the most successful survivor and as such each person will do what he of she has to do to survive and prosper in the situation they find themselves in - in aged care it is in the free market.  The explanations offered above are an attempt to explain why and how we do this.

Because a culturopathy is built on ideas that do not accurately reflect the real world we find endless perverse incentives (temptations and pressures in the system). Sooner or later someone will find a way to do what the pressures require. When one gains an advantage others follow. Suitable simplistic justifications are offered to justify the lie to ourselves and to others.

It may be businessmen seeking advantage as described by Michael Pascoe in his insightful article about rorting in aged care in the Sydney Morning Herald or bureaucrats trying to find a way of protecting themselves from embarrassment by hiding what they do from scrutiny. Both find simplistic explanations and justifications for what they are doing while knowing but not acknowledging to themselves the moral and ethical implications or the adverse consequences.

As we've seen in countless arenas, from commission-driven financial planning to soap powder and cardboard box cartels, provide incentives and the means to rort a system and some people will rort it. The means in aged care at the heart of this one-in-eight over-claiming is the payment mechanism, the ACFI – Aged Care Funding Instruments.

Source: Aged care clients, staff set to pay for government crackdown Sydney Morning Herald 20 June 2016 Michael Pascoe

Bureaucrats in charge of the $22 billion National Disability ­Insurance Scheme want to avoid creating documents referring to a secret cost-cutting committee to thwart Freedom of Information laws, flagging the problem at a meeting of its advisers last week.

Ms Glanville said future briefings about the review into how the scheme could save money might have to be given orally, to avoid creating documents that would become discoverable under FOI.

Source: Don’t put it in writing, NDIS advisers told The Australian 26 May 2016 (Paywall)

As was revealed in the US Healthcare example being caught out and even being convicted and being under close government supervision for 5 years may not bring insight. The need for the bad faith self deception is so strong that the exposures and convictions are simply explained away.

Those who are now recruiting the community to lobby the government to restore funding are the same people that the government are punishing and stopping from rorting the community's money. They just don’t get it even though this is the second or even third time they have been found wanting.  But they never use words like rorting and fraud themselves. Maximising and even gaming the system is somehow different. It seems that because the law does not specifically prohibit what you are doing its somehow OK.

This is not the first time the sector has been called out for rorting the system either. In 2012, Department of Health and Ageing whistleblowers told the ABC that aged care providers were rorting government payments to prop up their profits rather than provide care for their residents. There were claims of falsely classifying their residents as high care when the providers aren’t actually providing any extra services.

The incentives are clearly there for aged-care providers to increase the ACFI funding they receive, whilst also cutting their staff costs. But how do they do that while increasing care to justify the increased ACFI?

Source: How the power of incentives got the aged care sector into trouble The Motley Fool. 21 June 2016

Finding a way out of this

Mankind in its successful evolution has developed its own contexts and it has done so through a system of beliefs (or ideologies).  As with all evolutionary processes this has taken us down blind alleys and only some have survived.  Others have resulted in major social pathology with millions of deaths.

But in evolving we are also developing the capacity to reflect and look at the contexts we are creating and our behaviour in these contexts from many different points of view.  This is a major change because it allows us to challenge the ideologies that create the contexts within which we live, identify those that are not working and change the contexts.   We have the capacity to create our own future if we have the courage and the will to do so.  

We need to constantly confront and assess this as we progress lest it slip into a new belief system and become another culturopathy.  This is the big problem with reform because reform implies a beliief in something. The last thing we want in aged care is another reform agenda and more deceptive marketing.  Instead we need to find ways of moving from where we are to where we want to be in a systematic step wise trial and review fashion carefully considering each step against what we see before us in the real world as we go.

So in the evolutionary process we can see ourselves as at a cross roads, with the certainty that ideology brings on the one hand and the uncertainty and challenge that reflection on our humanity brings on the other.  Currently we are in full retreat into ideology and untested "reform".  We are doing our best to escape from the uncertainty and challenge of reflection.  If we are to challenge and then making effective changes we need to start by creating a context that encourages reflection.

The Community Aged Care Hub

The proposed hub is intended to create a context where the pressures in the system are redirected so that the focus moves from profits to serving the customer.  The pressures to be willfuly blind or use Bad Faith to lie to yourself would be removed. The focus would be on the common good.  Owners and providers would be in a position where they could successfully strive for a "good faith" authentic identity.  Because of the diverse range of perspectives, all focused on the common good of the residents, any tendency to stray into illusionary beliefs is much more likely to be challenged.

While the critical first step for the proposed hub is to create an effective customer, and so address the failed market, its ultimate objective is to create a context that inhibits and prevents the development of a culturopathy.  For this to work it requires that civil society, at least as far as aged care is concerned, is rebuilt.   Civil society must become directly involved.  It should take control and responsibility for what happens in aged care - no matter to whom they delegate the actual provision of care.

Reinforced by accurate and reliable data these hubs would be in an excellent position to evaluate new ideas and come up with better ways to meet the needs of the elderly and place their interests and their desires in life at the heart of care.  They would ensure that choices and person centred care did not simply become a means to meet corporate or government objectives.  Instead of "all show and no go" they would become "all go".

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And yes it is a real problem

Perhaps you think that this is pie in the sky theoretical nonsense and not relevant for aged care.  I have picked out rare exceptions and am making a mountain out of a molehill. Here is an extract from the third of a series of 17 articles about aged care based on an in depth investigation done by the St. Louis Despatch in the USA in 2002 a year or so after the aged care bubble burst.  The first two are titled "Nation's nursing homes are quietly killing thousands"  and "Survivors of lost loved ones tell stories of broken trust"

The Post-Dispatch conducted interviews with and reviewed testimony of scores of nurses, aides and administrators across the nation. They told of nursing home residents going hungry or thirsty or being left to lie in their soiled beds for hours on end without being turned.

They talked of medical records being falsified to overstate the amount of food and fluid residents consumed or the medication they were given.

They told of trays of food being placed on tables across a room from bedridden patients who were then given no help to reach, let alone eat, the meal. In some cases, food was improperly prepared for residents with chewing or swallowing problems, making it impossible for them to eat. Aides often had to rush to get residents through meals, blending food with liquids into an unpalatable and almost inedible slush. Other times, aides spooned food so quickly that residents choked.

Others told of residents forced to survive on liquid supplements because staff members lacked time to feed them. Caregivers routinely told of having to tend for dozens of patients, making it impossible to change soiled linens and feed, bathe, groom, turn and exercise residents. Instead, workers found themselves in a triage mode, able only to address the most pressing needs. They admitted cutting corners to make the workload manageable.

"This isn't labor like picking tomatoes, or packing boxes," Sloan (nurse) said. "I have to believe the vegetables in our country are treated more gently than our elders."

Source: Woefully inadequate staffing is at the root of patient neglect St. Louis Post-Dispatch, 14 Oct 2002

How strange that we are hearing just these critricisms from families and staff in Australia. If you want more here is a link to the 17 articles in 2002. If you think this was temporary and politicians fixed it then here is a link to another 21 articles related to a similar investigation in California in 2015.  As a community we need to step in before we go any further down this path..

And were we warned when we embarked on this path? Well yes by an Australian academic who had done research on the health sector in the USA way back in 1992. He wrote a book about it. After ridiculing the book as dystocian our medical profession did eventually get the message as did our state health departments. Between them they stepped in and stopped most of it.  But they don’t have the power to do it in aged care because the regulations that would have allowed them to do so were repealed in 1997.

"--- a huge and depressing departure from the system as they (readers) now know it."

"I see little but doom and gloom"

"----, whether Australians like it or not, and they certainly will not, the new century will see the Australian Health industry controlled by overseas megacorps, part of an international oligopoly, whose primary concern will be measured in terms of the profits derived from its exploitation of the local population and its indigenous labour force"

There is not much chance that this recognition will come in time, in the next few years. (page 191)

The might of the megacorps is formidable; they are practised in the use of politics, and power and wealth, in getting their own way. The only way that this nation can impose its will on any of them is to do so as a nation; ------ (Page 197)

---- will not pay over their capital unless they can run their businesses along the free enterprise lines that they think fit. (page 195)

Source: Extracts from ”Remission Impossible" Ron Williams (1992)

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