Being at Bethlem

Olivia Bladen reports on her internship at the Bethlem Hospital Museum and Archives, offered as part of Birkbeck’s MA in Victorian Studies. During her time there, she looked into ‘over-study’ as a trigger for madness.On my first day at Bethlem Museum of the Mind archivist Colin Gale gives me a tour through the stacks, beginning with an important disclaimer. When I ask about personal ephemera left behind by former patients, such as letters – a common question, I later find out – he explains that this is not the nature of the records kept by the hospital, and that medical case-notes are about as personal as they get. I realise this makes sense: it would be invasive for the hospital systematically to collect personal affects in this way. But Colin understands why I asked. The history of Bethlem psychiatric hospital – or ‘Bedlam’, as it was notoriously known, giving us the colloquialism for ‘chaos’ still in use to this day – is sprawling, and often unsavoury. It brings to mind untold cruelties and tragedies, as we imagine the lost histories of misunderstood and mistreated residents. The desire to hear their stories, from their own points of view, is one most visitors to the museum and archives will feel.

However, as Colin pulls out Victorian admissions registers and case books, I realise that although I will have to do some reading between the lines, this may be a far more rewarding endeavour than I anticipated. Already, I can see stories unfolding in spidery handwriting, emerging through snippets of just a few sentences long. I’m particularly interested in a column in the general admission registers, the first recorded contact a patient would have with Bethlem, citing their ‘supposed cause of insanity’. This was to become the basis of my independent research, after I notice the term ‘over study’ crops up repeatedly. For the next six weeks, I go through every register from 1853 to 1888, noting down the details of each patient recorded with this given ‘cause’, then selecting specific case notes to explore further. I consult the writing of Dr George Savage, chief medical officer at Bethlem within my period, and many other Victorian psychiatrists, to try and understand how the term ‘over study’ was used. I even get to meet a current doctor from the hospital, Deji, who has been researching the same topic in his own time for twelve years. We are in agreement that concept of ‘over study’ was, even in the nineteenth century, not understood as an underlying cause of mental health issues, but as a trigger.  Nevertheless, the abundance of the term in the records speaks of the anxieties that existed in the popular imagination around the time of industrial revolution and education reform.     

In addition to its paper archive, the Bethlem also boasts an impressive material collection in the museum upstairs. I find out that in its current iteration, situated in what was formerly the hospital’s administration building, it is only a few years old. In 1970, ‘Bethlem Royal Hospital Archives and Museum’, as it was then known, was housed in a much smaller structure – and, to all intents and purposes, was an archive rather than a museum, since there was so little room for display. But in 2015, it moved to its more spacious home, and in an impressive feat that rewards its ambition, was shortlisted for Museum of the Year Award the very next year.

It doesn’t take long for me to meet the team, which is very small. Colin tells me that unlike larger organisations, here everybody does a bit of everything, and no day is ever the same. Although I can see this is hard, I am drawn to this way of working. I’m fascinated by the questions and problems each and everybody fields each day. The reading room, which also serves as Colin’s office, seems to be a hub of activity.  On Tuesdays, volunteer Charlotte deals with copyright issues, phoning round for permission to show artworks either in displays or on the website. Another volunteer, Barbara, helps Colin respond to archival enquiries by locating obscure references that may or may not exist somewhere within the pages of meeting minutes or case notes. She is trained in reading eighteenth and nineteenth-century handwriting, and often helps me decipher tricky passages that look like little more than inkblots to me.  Other days, I observe Learning Officer Caroline Smith deliver some public programming: a workshop around patient consent given to students on a psychology course; and the museum’s first audio-described tour of the collection for blind and partially-sighted visitors.

I’m keen to get more involved. I’ve arrived at the end of one exhibition and in time for the installation of Scaling the Citadel: The Art of Stanley Lench, which showcases his psychedelic, stained-glass influenced images that speak of beauty and celebrity. As part of the programming around the exhibition, Bethlem are running what they call ‘Fame and Misfortune’ tours, in which volunteers will give a five-minute talk about a famous resident or person associated with Bethlem. They’re looking for someone to give a talk on Charlotte Brontë – as a Victorian scholar, I feel I ought to step in. The talk is on a Saturday, given after a short tour of the museum by Colin. I explain how it’s thought that Brontë visited Bethlem when it was located in Lambeth, on one of her jaunts to London shortly before her death – but we can’t be sure, since she did not sign her name in the visitor book.

My talk leaves me feeling better prepared for the presentation I will give on my research this July, and it also reinforces my reluctance to leave Bethlem, as I’m caught up in the atmosphere of the Saturday opening. I bump into new director Suzie Walker-Millar, who offers me the opportunity to work on a project where I consult with volunteers about frequently-asked visitor questions to help improve training. I’m also looking forward to joining them as a front-of-house volunteer as soon as I can; and developing a learning resource with Caroline. My research project is over, but I’m not ready for my experience at Bethlem to end. I came there looking for its stories – now I hope I can be one of them.

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Public-Private Partnerships viewed through a gender lens

In a new paper, published in the Journal of International and Comparative Social Policy, Dr Jasmine Gideon argues that despite their current popularity, Public-Private Partnerships need to be reviewed through a gender lens in order to establish whether they are really enabling the health sector to address wider social determinants of health and to ensure the longer-term success of any pro-women healthcare interventions.

Credit: Russell Watkins/Department for International Development.

Credit: Russell Watkins/Department for International Development.

Good health and sustainable development are widely acknowledged to be inextricably linked, and the promotion of health and well-being is an essential element in the Sustainable Development Goals (SDGs).  Within SDG3, ‘Ensure healthy lives and promote wellbeing for all at all ages’, governments have pledged to ensure universal access to sexual and reproductive health (SRH) care services by 2030.

One of the approaches often cited as necessary to provide universal access is through Public-Private Partnerships (PPPs) in health. The term PPP has been used in a variety of different contexts, but in the case of delivery of SRH services, PPPs have been used to fund and implement social franchising and health care voucher programmes in the Global South. They typically tie the recipient to a specified good or service package, such as medical consultations during pregnancy, provided by specified service providers who are often private practitioners or private sector facilities.  The approaches have grown in popularity since 2000 because:

  • they have been promoted by a range of aid donors including DFID and USAID
  • they are relatively easy to administer and to measure and monitor,
  • they are considered to be a way of encouraging poor households to use services e.g. family planning that they would not otherwise access.

However, there is criticism about the lack of evidence to sustain the claims made about the effectiveness of PPPs in improving access to health care services, and a recent paper by Benjamin M. Hunter, Susan F. Murray and I has argued that such PPPs may do little to address gender inequalities in health. We highlight the need to apply a ‘gender lens’ to the debate around the effectiveness of PPPs in SRH. We propose three key questions that should be asked of all PPP programmes to determine whether issues of gender inequality have been considered:

  1. What are the assumptions underpinning agendas in SRH-PPP interventions?
  2. How are SRH-PPP programmes framed and judged?
  3. To what extent do the SRH-PPP interventions take into account, reinforce or confront the existing realities of gendered social and economic life?

Applying these questions to a case study of a voucher scheme in India, we found that the design of the voucher programme was based on an assumed relationship between use of formal healthcare and decreased mortality and fertility, and the assumed superior effectiveness of private healthcare ‘markets’. The programme was framed as ‘innovative’ yet programme documents indicate the emphasis was on demonstrating rather than testing vouchers as a healthcare delivery model, and claims of success were made based on changes in healthcare use that were not adjusted for government programmes running concurrently.

The scheme in India did little to confront gender norms and values that are deeply embedded within health systems as well as the households that interact with them. For example despite the claims in programme documents to give pregnant women a choice of facility where they wish to give birth, in reality the decision was made by a husband, mother-in-law, female community health worker or the worker’s male supervisor.

The case study also shows that while PPPs claim to address gender-based inequalities, they do so within a limited framework whose simplistic focus on the gaps in women’s health fails to consider the socially constructed relations between men and women. Such PPPs therefore become part of a wider trend of interventions that have contributed to the depoliticization of women’s health and instead maintain a simplistic focus on maternal health that ignores the gendered power relations.

We argue that despite their adoption as the buzzwords of the moment it is not clear that PPP arrangements move us closer towards the ability of the health sector to address the wider social determinants of health that are critical to ensuring the longer-term success of any pro-women healthcare intervention. Applying a gender lens to review the evidence is one way that we can move closer to this goal.

Further information:

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The Seasons in Quincy UK release

On 23 June The Seasons in Quincy: Four Portraits of John Berger, a film produced by Birkbeck’s Derek Jarman lab, will be released in the UK and Ireland, screening in cinemas in London, Glasgow, Manchester and Bristol, among others. It will also be available online via Curzon Home Cinema, and a DVD will come out in August. Lily Ford, Deputy Director of the Derek Jarman Lab and producer of the film, explains the significance of the film’s cinematic release for research-based film-making.

siq_ukquad_master_medThe Seasons in Quincy is the first feature-length documentary to be produced by the Derek Jarman Lab, Birkbeck’s audiovisual hub, and was made by graduate students there (Lily Ford, Bartek Dziadosz and Walter Stabb) in collaboration with Tilda Swinton, Christopher Roth, Simon Fisher Turner and Colin MacCabe.

The Seasons started out as a film-making exercise, and the open-endedness of the project as it evolved over several years allowed for a great degree of creative freedom and experiment. We were extremely lucky to have the goodwill of John Berger, and the close involvement of Tilda Swinton. We travelled to the Alps as a capsule crew, conducting our shoots as efficiently and unobtrusively as possible and without a script or fixed shotlist, then spent a long time editing each part of the film. It took two years to find the right edit for the first part of the film, ‘Ways of Listening’; we then used this to raise funds for three more chapters from the Silicon Valley Community Foundation and the Pannonia Foundation, via the University of Pittsburgh. The nature of the funding, and our home within Birkbeck, enabled the Lab to give the process the necessary time, and to involve other Birkbeck students in filming, editing and disseminating the finished film.

Over 2016 the film had a vigorous festivals run, and was distributed in the US and Canada, making us realise that there was a wider audience and some commercial potential for it. We were really delighted to get UK and Ireland distribution this year, both as recognition of the quality of the film, and to enable a broader public around the two countries to watch it on big and small screens. It is almost unprecedented for a British university to produce a feature film that is commercially viable; Birkbeck and the Derek Jarman Lab have done this.

John Berger’s humanist commitment, accessible erudition and generosity of spirit is already well known, and it gives all of us great pleasure to have preserved this in the film, now that he is no longer with us. He was of course no stranger to the camera, and we were able to draw on his broadcast past in The Seasons; in this respect the film consists of many more than four portraits. The essayistic approach we took, a hallmark of the Lab’s modus operandi, makes the film very different from a classic biographical documentary and allows space for quite unique forms of engagement with Berger’s work. The critical reception of the film, as well as the warm audience response, confirms that it is a necessary and rewarding approach.

It is this kind of filmmaking – collaborative, innovative and intellectually engaged – that a university-based organisation such as the Derek Jarman Lab can undertake. We continue to advocate for research-based filmmaking, reaching out to graduate students and faculty at Birkbeck and encouraging them to think with film. While digital video and online platforms have made the moving image a very accessible medium for research output, the success of The Seasons in Quincy shows there is also scope for more long-form and cinematic enterprises from within the academic environment.

Further information:

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Making a market for acts of God

How is the damage of major global disasters paid for? And who by? Dr Rebecca Bednarek, Senior Lecturer in Management at Birkbeck, explores this in new book Making a Market for Acts of God, now available from Oxford University Press. 

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Catastrophic events appear to be increasing in both frequency and severity globally. The financial cost of their losses can be sudden and huge – but who pays the insurance bill for such massive events? Who paid for Hurricane Katrina, or 9/11, or the 2011 Tohuku earthquake?

It all comes from the ‘Reinsurance’ industry – a financial market that trades in the risk of major disasters. This means reinsurance is a crucial social and economic safety net that helps to mitigate some of the effects of disasters, both financially and in terms of allowing for a swifter rebuilding of people’s day-to-day lives following destruction or damage. Dr Rebecca Bednarek, Senior Lecturer in Management at Birkbeck uncovers the everyday realities of the reinsurance market in her book, Making a Market for Acts of God, co-authored with Professor Paula Jarzabiwski and Dr Paul Spee. They get to the bottom of how the risk of such disasters can be calculated and traded in a global market.

rebecca-bednarek_photoIn a recent interview for BBC Radio 4’s programme Thinking Allowed, Bednarek explains: ‘In the reinsurance industry, the increase and frequency of weather related events are put in the context of climate change. In addition, what is also happening is increased urbanisation; as cities get bigger, the losses and expenses of these events become more expensive, as more people are insured in localised settings.’ Further, increasingly, a natural disaster in one country could affect significant losses to supply chains in businesses around the world, and it is against this backdrop of increased globalisation that we must attach more significance to understanding the market of reinsurance.

The sheer scale of the claims means risk must be spread further in order to mitigate its effects – the attacks on the World Trade Centre in 2001 insured losses of $35.5 billion, for example, and for Hurricane Katrina in 2005 the payout was $46 billion. But as Bednarek says: ‘It’s not just the scale of this loss, it’s the fact that you couldn’t predict them. The reason reinsurers are able to themselves survive and to weather such large claims is because for each individual insurance deal, multiple reinsurers take a small part of this deal. No one reinsurer is exposed themselves to a single risk.’ The book also explains how long-term trust-based relationships between insurers and reinsurers are crucial to enabling and stabilising capital flows before and following these large-scale events. These relationships also enable reinsurers to build up deep contextual knowledge of specific risks; something which remains crucial in informing their judgement about risk even as they also use highly technical vendor models and actuarial techniques.

acts-of-god-book-cover

Bednarek and her co-authors shadowed underwriters from various different countries for over three years, gathering ethnographic observations from reinsurers in Bermuda, Lloyd’s of London, Continental Europe and South East Asia, studying their trading activities across many disaster situations.

There may be some developments in the reinsurance industry which could cause future problems, however. Bednarek says: ‘What we found was a whole milieu of long-standing social practices that had ensured that this industry had worked’ and provided capital to underpin large scale catastrophes for centuries. However towards the end of their period of engagement, the researchers began to observe ‘a period of rapid change; things like collatorised forms of finance, different kinds of deals that were changing the industry in certain ways. We wonder what these changes might do to some of these long existing practices that we identified as integral to this market and how it works.’

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