Mothers betrayed

Every year half a million women die in childbirth, deaths easily prevented. Here Sarah Brown, wife o

Two weeks ago, at Mulago Hospital in Kampala, I sat down next to a mother called Sylvia, resting in bed with her newborn baby after a successful delivery, nearly ready to return to her husband and five older children.

But I also looked through a window into a room containing eight babies, none more than two days old, their little cots covered in malaria nets. The doctors explained to me that in each of these cases, and hundreds more like them in the same hospital each year, the mother had died in childbirth.

The causes of death varied from bleeding and infection to high blood pressure and failure to survive a Caesarean section - all so easily preventable by modern western standards. In Britain, for the same reasons, the death of a mother in childbirth was once a common hazard, a fixture of Victorian life.

Improvements over the past century in antenatal care, health education, and obstetric and gynaecological care have lowered the risks of childbirth. There may be more to do at home, particularly on the health risks to newborn babies. But nowadays, only seven in 100,000 women die when giving birth in Britain.

In sub-Saharan Africa, the conditions and health care for mothers in childbirth are often no better, and sometimes far worse, than we had in Victorian times. In 1987, more than 500,000 women were dying in pregnancy or childbirth every year across the world, 99 per cent of them in developing countries. More than half of all women were delivering their babies with no skilled birth attendant present.

It was because of this terrible toll that 20 years ago, the Global Safe Motherhood Initiative was launched by the World Health Organisation to try to reduce the rates of maternal death. In 2000, the United Nations recognised the shocking rates of maternal death and made their reduction one of the Millennium Development Goals. The fifth MDG committed the wealthiest nations to cut maternal mortality by three-quarters between 1990 and 2015.

Tragically, 20 years after the Global Safe Motherhood Initiative, seven years after the UN Millennium Summit, no progress has been made. If anything, the figures are worse. Of 211 million pregnancies worldwide in 2005, eight million women experienced life-threatening complications during pregnancy or childbirth.

Those with access to skilled care and services tended to survive. But 536,000 died, the vast majority in developing countries, 80 per cent of them totally avoidable. Millions more have continuing health difficulties following obstetric complications, making life after childbirth difficult and painful.

In sub-Saharan Africa, the number of mothers dying in childbirth is around one in 50: up to 100,000 women die each year, and hundreds of thousands of babies and older children are left without a mother.

Visit hospitals in Africa and it is easy to see why. While the Commonwealth Heads of Government Meeting was going on in Uganda, I visited labour wards and delivery rooms at Muhimbili Hospital in Dar es Salaam and Mulago Hospital in Kampala. They are both huge referral hospitals attracting many women from across each city, and they offer the only real emergency obstetric care in their areas.

Mulago alone sees the delivery of 33,000 babies a year, almost one hundred a day. Compare that to the Edinburgh Royal Infirmary where my children were born, which is considered a big UK facility and where just 6,000 babies are delivered each year.

In all my visits, I saw overstretched services at work, committed teams with too few con sultants, nurses and midwives, and insufficient equipment and technical provision. Shortages included basic supplies such as sutures and painkillers, which run out whenever there is an extra-busy day for Caesarean sections or other emergency procedures.

The governments in Tanzania and Uganda are doing their best to make progress.

The Tanzanian president, Jakaya Kikwete, told me this was a personal passion for him, and that his government had pledged to put dispensaries around the country that could also offer antenatal care. In Uganda, I saw the nearly completed refurbishment of a maternity block in the Mulago Hospital grounds. But still the death toll remains stubbornly high.

And what makes the lack of any progress on maternal mortality so depressing and frustrating is that, on other Millennium Development Goals, some progress - albeit slowly - is being made and things are beginning to improve. Millions more children are surviving infancy, receiving vaccinations and going to primary school than were in 2000, their life chances transformed by better health care and education. Even in the uphill struggle against Aids, great progress is being made. In Uganda, HIV infection has fallen from 16 per cent to 5 per cent in the past decade.

Yet we know that for hundreds of thousands of children each year, the improvements we make to their life chances through better edu cation and health care are cancelled out by the loss of their mother. For every mother who dies in childbirth, the life chances of a new baby - as well as its brothers and sisters - can be damaged beyond repair.

Avoidable deaths

It is obviously harder for a child to survive, grow and have a life with choices if there is no mother to provide care, food, protection and education. The statistics bear this out. A study in Indonesia showed that 14 per cent of children aged six to ten who had lost mothers dropped out of school, compared to only 7 per cent of those who had not. Poverty as an adult was far more likely for the former group.

The same study showed that children without mothers were four times more likely to die in their early years - usually of malnutrition or disease - compared to other children.

Internationally, pressure is growing, through the White Ribbon Alliance, a global campaign group dedicated to highlighting the avoidable tragedy of maternal death, supported by the WHO's Making Pregnancy Safer campaign and the Partnership for Maternal, Newborn and Child Health. In the UK, the White Ribbon Alliance is led by the Royal College of Obstetricians and Gynaecologists (RCOG) and I sit on its international advisory group. This has given me the opportunity to meet some of the world's leading experts in this field. It has opened my eyes to the impact of maternal death on the life chances of infants.

The general causes are well understood: high fertility rates lead to greater pressure on resources, inadequate and inaccessible health care makes childbirth inherently risky, and women's low status economically and culturally affects their access to health services and the priority they are given.

There is also broad agreement on the solutions required: greater resources, better education, better access to emergency care, availability of antenatal care to spot problems in advance and quick referrals for mothers with complications.

The RCOG International Office has designed a course teaching young consultants essential obstetric and newborn care. The course is available in Tanzania and Kenya, and I hope it will soon be extended to Uganda. Accompanied by Tony Falconer, RCOG senior vice-president, I met a young doctor in the antenatal clinic at Muhimbili Hospital who had completed the course two months before, and thought his training had already helped him save lives.

The RCOG is taking this work further. In South Africa, it is working to help obstetric experts develop a training package for all local doctors in their third postgraduate year, generally spent in more remote conditions. Momentum is building. I am hopeful that a special session will be devoted to maternal death at next year's international summit in Davos and the Bill and Melinda Gates Foundation is funding projects around the world to raise awareness.

At home, just over a month ago, the International Development Secretary, Douglas Alexander, announced at a conference in London that the UK would commit an extra £100m towards improvements in reproductive health. To meet any of the Millennium Development Goals, we need the will, the means and the momentum. We have seen this in relation to vaccinations, free education and the fight against Aids. Now we must see it on the issue of maternal death, where no significant progress has been made, not just in the past seven years, but in the past two decades.

Each developing country needs a strategic health plan that takes account of local situations, expanding services so that populated central and remote areas alike acquire trained people and resources. The investment needed to improve maternal health is small, but the gains for the poorest children in the world will be huge. We must make 2008 the first year of progress on this neglected Millennium Development Goal.

Sarah Brown sits on the international advisory board of the Royal College of Obstetricians. As founder of the Jennifer Brown Fund, she has been closely involved for the past six years in the area of infant and maternal health

This article first appeared in the 10 December 2007 issue of the New Statesman, How New Labour turned toxic

JOHN DEVOLLE/GETTY IMAGES
Show Hide image

Fitter, dumber, more productive

How the craze for Apple Watches, Fitbits and other wearable tech devices revives the old and discredited science of behaviourism.

When Tim Cook unveiled the latest operating system for the Apple Watch in June, he described the product in a remarkable way. This is no longer just a wrist-mounted gadget for checking your email and social media notifications; it is now “the ultimate device for a healthy life”.

With the watch’s fitness-tracking and heart rate-sensor features to the fore, Cook explained how its Activity and Workout apps have been retooled to provide greater “motivation”. A new Breathe app encourages the user to take time out during the day for deep breathing sessions. Oh yes, this watch has an app that notifies you when it’s time to breathe. The paradox is that if you have zero motivation and don’t know when to breathe in the first place, you probably won’t survive long enough to buy an Apple Watch.

The watch and its marketing are emblematic of how the tech trend is moving beyond mere fitness tracking into what might one call quality-of-life tracking and algorithmic hacking of the quality of consciousness. A couple of years ago I road-tested a brainwave-sensing headband, called the Muse, which promises to help you quiet your mind and achieve “focus” by concentrating on your breathing as it provides aural feedback over earphones, in the form of the sound of wind at a beach. I found it turned me, for a while, into a kind of placid zombie with no useful “focus” at all.

A newer product even aims to hack sleep – that productivity wasteland, which, according to the art historian and essayist Jonathan Crary’s book 24/7: Late Capitalism and the Ends of Sleep, is an affront to the foundations of capitalism. So buy an “intelligent sleep mask” called the Neuroon to analyse the quality of your sleep at night and help you perform more productively come morning. “Knowledge is power!” it promises. “Sleep analytics gathers your body’s sleep data and uses it to help you sleep smarter!” (But isn’t one of the great things about sleep that, while you’re asleep, you are perfectly stupid?)

The Neuroon will also help you enjoy technologically assisted “power naps” during the day to combat “lack of energy”, “fatigue”, “mental exhaustion” and “insomnia”. When it comes to quality of sleep, of course, numerous studies suggest that late-night smartphone use is very bad, but if you can’t stop yourself using your phone, at least you can now connect it to a sleep-enhancing gadget.

So comes a brand new wave of devices that encourage users to outsource not only their basic bodily functions but – as with the Apple Watch’s emphasis on providing “motivation” – their very willpower.  These are thrillingly innovative technologies and yet, in the way they encourage us to think about ourselves, they implicitly revive an old and discarded school of ­thinking in psychology. Are we all neo-­behaviourists now?

***

The school of behaviourism arose in the early 20th century out of a virtuous scientific caution. Experimenters wished to avoid anthropomorphising animals such as rats and pigeons by attributing to them mental capacities for belief, reasoning, and so forth. This kind of description seemed woolly and impossible to verify.

The behaviourists discovered that the actions of laboratory animals could, in effect, be predicted and guided by careful “conditioning”, involving stimulus and reinforcement. They then applied Ockham’s razor: there was no reason, they argued, to believe in elaborate mental equipment in a small mammal or bird; at bottom, all behaviour was just a response to external stimulus. The idea that a rat had a complex mentality was an unnecessary hypothesis and so could be discarded. The psychologist John B Watson declared in 1913 that behaviour, and behaviour alone, should be the whole subject matter of psychology: to project “psychical” attributes on to animals, he and his followers thought, was not permissible.

The problem with Ockham’s razor, though, is that sometimes it is difficult to know when to stop cutting. And so more radical behaviourists sought to apply the same lesson to human beings. What you and I think of as thinking was, for radical behaviourists such as the Yale psychologist Clark L Hull, just another pattern of conditioned reflexes. A human being was merely a more complex knot of stimulus responses than a pigeon. Once perfected, some scientists believed, behaviourist science would supply a reliable method to “predict and control” the behaviour of human beings, and thus all social problems would be overcome.

It was a kind of optimistic, progressive version of Nineteen Eighty-Four. But it fell sharply from favour after the 1960s, and the subsequent “cognitive revolution” in psychology emphasised the causal role of conscious thinking. What became cognitive behavioural therapy, for instance, owed its impressive clinical success to focusing on a person’s cognition – the thoughts and the beliefs that radical behaviourism treated as mythical. As CBT’s name suggests, however, it mixes cognitive strategies (analyse one’s thoughts in order to break destructive patterns) with behavioural techniques (act a certain way so as to affect one’s feelings). And the deliberate conditioning of behaviour is still a valuable technique outside the therapy room.

The effective “behavioural modification programme” first publicised by Weight Watchers in the 1970s is based on reinforcement and support techniques suggested by the behaviourist school. Recent research suggests that clever conditioning – associating the taking of a medicine with a certain smell – can boost the body’s immune response later when a patient detects the smell, even without a dose of medicine.

Radical behaviourism that denies a subject’s consciousness and agency, however, is now completely dead as a science. Yet it is being smuggled back into the mainstream by the latest life-enhancing gadgets from Silicon Valley. The difference is that, now, we are encouraged to outsource the “prediction and control” of our own behaviour not to a benign team of psychological experts, but to algorithms.

It begins with measurement and analysis of bodily data using wearable instruments such as Fitbit wristbands, the first wave of which came under the rubric of the “quantified self”. (The Victorian polymath and founder of eugenics, Francis Galton, asked: “When shall we have anthropometric laboratories, where a man may, when he pleases, get himself and his children weighed, measured, and rightly photographed, and have their bodily faculties tested by the best methods known to modern science?” He has his answer: one may now wear such laboratories about one’s person.) But simply recording and hoarding data is of limited use. To adapt what Marx said about philosophers: the sensors only interpret the body, in various ways; the point is to change it.

And the new technology offers to help with precisely that, offering such externally applied “motivation” as the Apple Watch. So the reasoning, striving mind is vacated (perhaps with the help of a mindfulness app) and usurped by a cybernetic system to optimise the organism’s functioning. Electronic stimulus produces a physiological response, as in the behaviourist laboratory. The human being herself just needs to get out of the way. The customer of such devices is merely an opaquely functioning machine to be tinkered with. The desired outputs can be invoked by the correct inputs from a technological prosthesis. Our physical behaviour and even our moods are manipulated by algorithmic number-crunching in corporate data farms, and, as a result, we may dream of becoming fitter, happier and more productive.

***

 

The broad current of behaviourism was not homogeneous in its theories, and nor are its modern technological avatars. The physiologist Ivan Pavlov induced dogs to salivate at the sound of a bell, which they had learned to associate with food. Here, stimulus (the bell) produces an involuntary response (salivation). This is called “classical conditioning”, and it is advertised as the scientific mechanism behind a new device called the Pavlok, a wristband that delivers mild electric shocks to the user in order, so it promises, to help break bad habits such as overeating or smoking.

The explicit behaviourist-revival sell here is interesting, though it is arguably predicated on the wrong kind of conditioning. In classical conditioning, the stimulus evokes the response; but the Pavlok’s painful electric shock is a stimulus that comes after a (voluntary) action. This is what the psychologist who became the best-known behaviourist theoretician, B F Skinner, called “operant conditioning”.

By associating certain actions with positive or negative reinforcement, an animal is led to change its behaviour. The user of a Pavlok treats herself, too, just like an animal, helplessly suffering the gadget’s painful negative reinforcement. “Pavlok associates a mild zap with your bad habit,” its marketing material promises, “training your brain to stop liking the habit.” The use of the word “brain” instead of “mind” here is revealing. The Pavlok user is encouraged to bypass her reflective faculties and perform pain-led conditioning directly on her grey matter, in order to get from it the behaviour that she prefers. And so modern behaviourist technologies act as though the cognitive revolution in psychology never happened, encouraging us to believe that thinking just gets in the way.

Technologically assisted attempts to defeat weakness of will or concentration are not new. In 1925 the inventor Hugo Gernsback announced, in the pages of his magazine Science and Invention, an invention called the Isolator. It was a metal, full-face hood, somewhat like a diving helmet, connected by a rubber hose to an oxygen tank. The Isolator, too, was designed to defeat distractions and assist mental focus.

The problem with modern life, Gernsback wrote, was that the ringing of a telephone or a doorbell “is sufficient, in nearly all cases, to stop the flow of thoughts”. Inside the Isolator, however, sounds are muffled, and the small eyeholes prevent you from seeing anything except what is directly in front of you. Gernsback provided a salutary photograph of himself wearing the Isolator while sitting at his desk, looking like one of the Cybermen from Doctor Who. “The author at work in his private study aided by the Isolator,” the caption reads. “Outside noises being eliminated, the worker can concentrate with ease upon the subject at hand.”

Modern anti-distraction tools such as computer software that disables your internet connection, or word processors that imitate an old-fashioned DOS screen, with nothing but green text on a black background, as well as the brain-measuring Muse headband – these are just the latest versions of what seems an age-old desire for technologically imposed calm. But what do we lose if we come to rely on such gadgets, unable to impose calm on ourselves? What do we become when we need machines to motivate us?

***

It was B F Skinner who supplied what became the paradigmatic image of ­behaviourist science with his “Skinner Box”, formally known as an “operant conditioning chamber”. Skinner Boxes come in different flavours but a classic example is a box with an electrified floor and two levers. A rat is trapped in the box and must press the correct lever when a certain light comes on. If the rat gets it right, food is delivered. If the rat presses the wrong lever, it receives a painful electric shock through the booby-trapped floor. The rat soon learns to press the right lever all the time. But if the levers’ functions are changed unpredictably by the experimenters, the rat becomes confused, withdrawn and depressed.

Skinner Boxes have been used with success not only on rats but on birds and primates, too. So what, after all, are we doing if we sign up to technologically enhanced self-improvement through gadgets and apps? As we manipulate our screens for ­reassurance and encouragement, or wince at a painful failure to be better today than we were yesterday, we are treating ourselves similarly as objects to be improved through operant conditioning. We are climbing willingly into a virtual Skinner Box.

As Carl Cederström and André Spicer point out in their book The Wellness Syndrome, published last year: “Surrendering to an authoritarian agency, which is not just telling you what to do, but also handing out rewards and punishments to shape your behaviour more effectively, seems like undermining your own agency and autonomy.” What’s worse is that, increasingly, we will have no choice in the matter anyway. Gernsback’s Isolator was explicitly designed to improve the concentration of the “worker”, and so are its digital-age descendants. Corporate employee “wellness” programmes increasingly encourage or even mandate the use of fitness trackers and other behavioural gadgets in order to ensure an ideally efficient and compliant workforce.

There are many political reasons to resist the pitiless transfer of responsibility for well-being on to the individual in this way. And, in such cases, it is important to point out that the new idea is a repackaging of a controversial old idea, because that challenges its proponents to defend it explicitly. The Apple Watch and its cousins promise an utterly novel form of technologically enhanced self-mastery. But it is also merely the latest way in which modernity invites us to perform operant conditioning on ourselves, to cleanse away anxiety and dissatisfaction and become more streamlined citizen-consumers. Perhaps we will decide, after all, that tech-powered behaviourism is good. But we should know what we are arguing about. The rethinking should take place out in the open.

In 1987, three years before he died, B F Skinner published a scholarly paper entitled Whatever Happened to Psychology as the Science of Behaviour?, reiterating his now-unfashionable arguments against psychological talk about states of mind. For him, the “prediction and control” of behaviour was not merely a theoretical preference; it was a necessity for global social justice. “To feed the hungry and clothe the naked are ­remedial acts,” he wrote. “We can easily see what is wrong and what needs to be done. It is much harder to see and do something about the fact that world agriculture must feed and clothe billions of people, most of them yet unborn. It is not enough to advise people how to behave in ways that will make a future possible; they must be given effective reasons for behaving in those ways, and that means effective contingencies of reinforcement now.” In other words, mere arguments won’t equip the world to support an increasing population; strategies of behavioural control must be designed for the good of all.

Arguably, this authoritarian strand of behaviourist thinking is what morphed into the subtly reinforcing “choice architecture” of nudge politics, which seeks gently to compel citizens to do the right thing (eat healthy foods, sign up for pension plans) by altering the ways in which such alternatives are presented.

By contrast, the Apple Watch, the Pavlok and their ilk revive a behaviourism evacuated of all social concern and designed solely to optimise the individual customer. By ­using such devices, we voluntarily offer ourselves up to a denial of our voluntary selves, becoming atomised lab rats, to be manipulated electronically through the corporate cloud. It is perhaps no surprise that when the founder of American behaviourism, John B Watson, left academia in 1920, he went into a field that would come to profit very handsomely indeed from his skills of manipulation – advertising. Today’s neo-behaviourist technologies promise to usher in a world that is one giant Skinner Box in its own right: a world where thinking just gets in the way, and we all mechanically press levers for food pellets.

This article first appeared in the 18 August 2016 issue of the New Statesman, Corbyn’s revenge