Beyond Empathy to System Change: Four Poems on Health by Bertolt Brecht

The canalization of a river 
The grafting of a fruit tree 
The education of a person 
The reconstruction of a state. 
These are all instances of a fruitful critique 
And they are also
 Instances of art. 
—Bertolt Brecht, “On the Critical Attitude”

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HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

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'The education of a person'	'The canalization of a river The grafting of a fruit tree'
'These are all instances of a fruitful critique And they are also Instances of art.' —Bertolt Brecht, “On the Critical Attitude”	'The reconstruction of a state.'

MacGregor, W., Horn, M. & Raphael, D. Beyond Empathy to System Change: Four Poems on Health by Bertolt Brecht. J Med Humanit 45, 53–77 (2024). https://doi.org/10.1007/s10912-023-09801-5

My source: 

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See also: 'drama' : 'empathy' : 'poetry' : 'change' : 'art'

On Sociology & Becoming a Patient

'The Subject matter of Sociology
& Becoming a Patient'

A primer for my picking up Hodges' model, or being pressed onboard, was early exposure to history and sociology. There was an understandable emphasis in the (then) school of nursing (registered mental nursing) on the role of society, social history, lunacy and the asylums, law, and attitude towards mental illnesses.

Continuing to sort books (inc. secondhand) and papers, there is:

Maclean, Una. (1974) Nursing in contemporary society. London: Routledge & Kegan Paul.

https://wellcomecollection.org/works/qhqc24fv

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'The sociological viewpoint can be taken on many different subjects. Thus, political sociology has to do with people's voting behaviour and their reactions to the processes of government, while the sociology of education takes into account the influence of various social factors upon educational opportunities and achievements. In addition, social psychology, social psychiatry and social medicine are all related to medical sociology. These terms all imply the use of sociological methods and insights in different areas of human behaviour, and the divisions between them are a convenient way of dealing with what is a very wide territory. Such divisions may suggest that events and things in the real world are already separated in themselves, whereas the divisions are actually in the minds of the people who make them. It is easier to regard sociology generally as being the study of people's behaviour in groups, groups of all kinds, large and small, casual or permanent, groups of which people are very conscious as well as those of which they may scarcely be aware. Thus, much of sociology is concerned with the human family, a group whose form and composition varies from one part of the world to another and from one set of people to another but which does have common features and functions wherever it is studied. The family will be referred to repeatedly in this book, since not only does it affect all our lives but it profoundly influences the way in which people react in relation to illness.' pp.8-9.

Maclean pointed to the 'innumerable other human groupings' (p.9) and how these - family, schools, clubs, professional training, friendships, audiences, tourist crowds, customers, villager, hostel dweller; such groupings, some historic, temporary or transient - also differentiate into populations, that inform epidemiological and demographic studies. 

It is remarkable how societies have changed globally, since Maclean's 1974 text.

As if to presage the one-to-one encounters to follow, chapter 2 'Becoming a patient' after a brief history 'sickness' arrives at the work of the American sociologist Talcott Parsons.

I don't have the date but I remember making a note the four combined conditions at work for an individual to adopt the sick role. What stood out was how something we think is individually determined is social and so often a question of permission.

Maclean's text (with my emphasis) on these factors follows; and is then mapped to the domains of Hodges' model:

'In the first place, the illness must be outside the patient's control, in no sense his own fault. Second, the sick role will allow him exemption from his other roles. with their associated obligations and duties. For example, a man can legitimately give up work and leave his usual family 'responsibilities to his wife. But, third, the sick role requires that the patient should positively desire to get well, he should not relish the relinquishment of responsibility and, fourth, he has the obligation to seek competent medical help.' p.25.

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the sick role requires that the patient should positively desire to get well	the illness must be outside the patient's control, in no sense his own fault.
the sick role will allow him exemption from his other roles. with their associated obligations and duties	he has the obligation to seek competent medical help

Again as an exercise you might care to reflect on this and our experiences since the millennium?

What is most remarkable is the need to view this as a 'future lesson' in terms of how societies must, will change to meet the challenges of tomorrow, and the day after that ...

Essay: 'Addressing health inequalities through employment' July 2025

Four priorities:

1. Establish closer working relationships across the SA [Strategic Authorities] ecosystem to prioritise action on health inequalities.  
   
   
2. Align resources to support people on their journey to sustainable employment.
   
   
3. Negotiate with government for greater permissions.
   
   
4. Harness the power of anchors.

 

Many useful references are also provided, e.g. Building Blocks of Health. Plus the discussion of anchors.

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 SOCIOLOGY  :    POLITICAL 

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Group

employment as a determinant of health mental & emotional health Early intervention, employer-employee liaison, health coaching*	PLACE - PLANET physical health - life-expectancy LOCAL - accessible
SOCIO- people & communities flourishing communities neighbourhood People in communities on  LONG-TERM SICKNESS WORKWELL grants* WIDER DETERMINANTS OF HEALTH SOCIAL VALUE OF HEALTH low-quality jobs - poorer health Poverty - HOUSING SECURITY	-ECONOMIC NHS 10 Year plan: 1. GP / dental access 2.  waiting lists hospital and community care 3. staff demoralised and demotivated 4. outcomes on major killers like cancer lag behind other countries. STRAGEIC AUTHORITIES - DEVOLUTION shift of wealth & power HEALTH INEQUALITIES inequity WHOLE GOVERNMENT APPROACH TO HEALTH ECONOMIC VALUE OF HEALTH low-quality jobs Local strategic response

See also -

Opinion: Failing to collect, analyse, and report ethnicity data in clinical research leads to healthcare inequalities. BMJ 2025; 390 doi: https://doi.org/10.1136/bmj.r1457 (Published 14 July 2025)
Cite this as: BMJ 2025;390:r1457

 'hospital' : 'community' : 'analogue' : 'digital' : 'prevention' : 'sickness'

My source: https://x.com/TheKingsFund/status/1944678280461734226

'Thinking outside the box ...' iii by Amber Javis

Third response to a blog post by Amber Jarvis on The Mental Elf:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

A Community Psychiatric Nurse since 1985, on first contact patients were often upset initially at the prospect of a visit. Not the fact it was a nurse, but a psychiatric, 'mental' nurse. If the patient was OK about it, their family may have had qualms. Discretion was always exercised, essential in terms of maintaining confidentialty. Not infrequently, as a team we had a conflict of interest. A colleague already had a client a few doors down; or they lived around the corner. Socio-politically, there was never an issue back then with shop fronts, but homelessness has a long history of course. I've worked in intermediate support, visiting someone 2-3 times in a day. That continuity helps, in contrast to the experience of older adults in social care. It could be that the potential stigma elicited by intensive home care is now attenuated by:

• The public's increased awareness mental health & illness;
• The fragmentation of neighbourliness means people really aren't interested?

In the conclusion on Griffith's et al's study Amber notes:

'The authors’ classification of alternative service models could help planners and commissioners understand ‘the whole range of options’ when deciding which improvements to prioritise and invest in.

However, future studies should investigate the implementation challenges surrounding these alternative models – that is, what might make certain models easier or more difficult to introduce? Research investigating their effectiveness in practice is also required – are there particular models that are better suited to certain individuals, at particular times? As the authors put it: “what works best for whom, when and how”!'

The government in England has launched a trial regards people who are sick, and their work status:

'GP surgeries in England can offer advice to patients on getting back to work, including career coaching or exercise classes, as part of a pilot project to reduce the number of people who are signed off work sick.

The aim is to help people return to the workplace more quickly to reduce the length of time they need fit notes - better known as sick notes.

These are issued by health professionals if a patient is unwell or cannot work for more than seven days.

A total of £1.5m is being made available to 15 regions in England, and will be shared between GP practices in these areas to hire coaches or occupational therapists to support patients in their return to work.'

Hugh Pym, Health editor: https://www.bbc.co.uk/news/articles/cwyx880d1w8o 

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Career coaching Exercise classes Counselling Reduce time spent 'ill - sick - off-work' Motivation - Mindset	FIT - SICK: physically only of course! Seven days What can't I do? What can I do?
Social Prescribing Occupational Therapists Physiotherapist Support workers Horticultural groups Local history	FIT NOTES - SICK NOTES £1.5m across 15 regions Policy Welfare budget Behavioural Economics Integrated Care & Social Policy

Given the rise of mental health related provblems in the population, some might argue that increased awareness of, and education about mental illnesses is part of the problem. But this isn't literacy then?

With the standing of the mental health nursing curriculum called into question, policymakers have some serious decisions to make. Social prescribers and care navigators are not the only people preoccupied with signposting. Griffith et al. write:

'Inpatient care is also costly; even though only 3% of people in England accessing mental health care in 2018/19 received inpatient mental health care, National Health Service (NHS) trusts in England still invest more in inpatient than community services [8].'

Hodges' model: Axes & Domains

You can appreciate just how far away prevention and a health literate population truly are. Budgets will have to be re-directed. Now that is 'care-ordination'.

Griffith et al. and Amber's response, calls care that is simultaneous person-centred and service-centred. 

In Hodges' model it is as if the vertical axis, is turned and the 'individual' aligned with the humanistic (person-centred) and group - the mechanistic (service-centred) axis. This gives us self-care, individualised healthcare, personalised medicine through to population health.

Griffith does not venture into literacy and education (not their study's purpose, of course); but using Hodges' model, we can see two critical related issues. In addition to reducing the time a person is physically, and mentally indisposed, unwell, ill, sick ...

1. We need to improve the lot of children excluded from school;
2. Seriously address the determinants of health socio-politically.

'Thinking outside the box ...' i

ii 'Thinking outside the box ...'

"In all flat maps (and I am one)" - Donne

'Discordia concors' - 'Concordia discors' ... plus ... 'Site map'*

"Drawing both on the medieval Mappae mundi and the Ptolemaic tradition revived in the Renaissance, the recurrent cartographic motif in John Donne’s poetry well reflects the preoccupations of a revolutionary period in the history of Western cartography. Yet, for all its cosmic magnitude, Donne’s poems, both holy and secular, are turned, not so much towards an exploration of the world as towards an exploration of the Self as the ultimate object of reflection." [Abstract].

Ladan Niayesh, ““All flat maps, and I am one”: Cartographic References in the Poems of John Donne”, Études Épistémè [Online], 10 | 2006, Online since 01 October 2006, connection on 22 February 2023. URL: http://journals.openedition.org/episteme/955; DOI: https://doi.org/10.4000/episteme.955

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"Let us take as a first example one of the last poems written by Donne, "Hymn to God my God, in my Sickness", composed either during one of the poet’s serious illnesses in 1623 or alternatively shortly before his death in 1631 ..."

"... Here the poet compares himself, as he lies on his sick-bed, or possibly his death bed, to a flat geographical map studied by his physicians who are compared to cartographers: "my physicians by their love are grown / Cosmographers, and I their map, who lie / Flat on this bed" (ll. 6-8), and later "In all flat maps (and I am one)" (ll. 14)."

The global Psycho-Social-Geo-Political legacies and future?

"Yet for all its symbolic Noachid and Christian background, Donne’s cartographic imagery has room for the latest scientific contributions. Newly discovered territories are directly named here: "is the Pacific Sea my home?" (l. 16), "Anyan, and Magellan, and Gibraltar" (l. 18). And if this metaphorical map is a flat one — "In all flat maps (and I am one)" — it is solely for the sake of commodity, as this flat shape actually stands for an acknowledged and accepted spherical reality: "west and east / In all flat maps (...) are one" (ll. 13-14)."

*I found some irony in 'site map' being the final map on the journal's webpage.

Sources:
 

London July 2022 Foyles, Waterstones and other bookshops:
Super-Infinite: The Transformations of John Donne (Hardback)

https://www.faber.co.uk/product/9780571345915-super-infinite/

BBC Radio 4 Super-Infinite by Katherine Rundell [Episode 3]

Previously on W2tQ: 'maps'

Hubris syndrome: Daedalus Project [Psycho-Political]

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Hubris Syndrome "Democratic politicians as diverse as Woodrow Wilson, Franklin D. Roosevelt, Churchill, Kennedy, Johnson, Nixon, Pompidou, Mitterrand, Blair, George W. Bush, Chirac, and Sharon all lied about their health. ...

... Between 1906 and 2008 seven Presidents are judged to have been mentally ill while in office: Theodore Roosevelt (bipolar disorder), Taft (breathing-related sleep disorder), Wilson (major depressive disorder), Coolidge (major depressive disorder), Hoover (major depressive disorder), Johnson (bipolar disorder), and Nixon (alcohol abuse). Many despots-such as Hitler, Stalin, Saddam Hussein, Pol Pot, Idi Amin, and Robert Mugabe-have been branded by the press and public opinion as suffering mental illnesses. Lord Owen argues neither Hitler nor Stalin were mad in any sense the medical profession recognizes (whereas Mussolini and Mao had depression, possibly bipolar disorder)."

'Faith' in leadership? 'Choice'?

In Sickness and in Power by Owen David

I remember Lord Owen's book being published, over a decade ago and heard radio interviews at the time (BBC Radio 4, Start the Week?). Not sure why I didn't pick this up as the disciplinary bridges are stark and clear (now!): PSYCHO-POLITICAL and GEO-PSYCHIATRIC. The importance of the issues the Daedalus Project addresses, now within Maudsley Philosophy Group is not just suddenly 'self' evident*, but is of importance for the world's population- impacting upon global safety and security.

Even since Lord Owen's book the rise of AI adds complexity (as ever).

 *irony intended.

Text: https://www.goodreads.com/book/show/3205306-in-sickness-and-in-power

Owen, D. (2009) In Sickness and in Power: Illnesses in Heads of Government during the Last 100 Years, London: Methuen Ltd.  ISBN: 978-0-413-77689-1

Plus via twitter: 

Thanks!

This is great talk from David Owen on Hubris syndrome we organised at @The_BNPA meeting a few years backhttps://t.co/73qGD42oQY

— Tim Nicholson (@Tim_R_Nicholson) March 6, 2022

Money and Mental Health [ii] OVERSTRETCHED, OVERDRAWN, UNDERSERVED

Following on from - Money and Mental Health [i] Impact of Mass Unemployment Events (MUEs)

I have been familiar with the relationship between mental health and finance since student days in the late 1970s. Debt was and remains a profound and common problem. This can exacerbate existing mental health problems or it be the trigger - the straw that breaks the camel's back. From the report:

One in four people with a mental health problem is also in problem debt, and half of people in financial difficulties have a mental health problem (p. 13).

Finance still has this impact whether it is a lack of basic financial skills (literacy), life chances and opportunity or attributed to bad luck. Speaking of 'luck': I have frequently felt angry and frustrated with government policy. It is common sense and statistically inevitable that within the population there will be people who are vulnerable to addiction of many sorts. Why make it easier for those who are vulnerable to potentially loose everything? Not only that but money impacts all those in vulnerable groups, not just people in work. When we talk of health inequality what is the biggest factor? I've come across instances of elderly people receiving scam mail and not just the 'odd' post. While within Hodges' model below I have family as a resource, sadly this can also be part of a problem.

'Productivity' looms large in the report and draws a rueful smile here. In the NHS productivity and its increase is a constant requirement. In the general economy UK productivity is low and seemingly stuck. Successive governments have failed and now with Brexit productivity is still on life-support.

In the report 'financial fragility' is a very useful construct (as with circumstantial, rather than careless overspending). The public sector is also highlighted in this regard:

Forecasts suggest that 5.4 million public sector workers, one in six of the UK workforce, will be worse off in 2020 than they were in 2010 (p.16).

Before you view the report itself and the small conceptual sampling in Hodges' model, the report refers to the hidden epidemic that this report seeks to highlight and represent. This government and successive, nationally and globally need to get to grips - somehow - with the hidden economy - parts of which are blatantly obvious in the subterfuge around tax avoidance. This is another relationship that operates upon us all - employed, unemployed, young and aged - and which Hodges' model can also help illuminate.


Evans, K., Holkar, M., Murray, N. (2017) OVERSTRETCHED,OVERDRAWN, UNDERSERVED: financial difficulty and mental health at work, The Money and Mental Health Policy Institute, May 2017.

What follows is drawn from the report above - with a couple of additions:

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[May THE KNOWLEDGE ECONOMY]  (including nursing) MENTAL HEALTH hidden epidemic ... over two thirds (67%) of employees who are struggling financially report at least one sign of poor mental health that could affect their ability to function at work loss of sleep, poor concentration, reduced motivation, preoccupation Increased risk taking (impact - occupation...?) Guilt/shame Anxiety Low self-esteem Anger Frustration Fear Low mood Self-harm Suicidal ideation Insomnia Panic attacks Depression, Lethargy/apathy Substance misuse [... starts here!]

PRODUCTIVITY Physical effects of anxiety, stress, alcohol, smoking (increase, relapse), other substance misuse physical fragility (lack of resilience) Nearly half (45%) of all working days lost to ill health were a result of stress in 2015/16 – adding up to 11.7 million days across the economy. work access to:   "on-site exercise facilities, healthy  food and rest spaces" hidden morbidity

Influence of individual mental health on colleagues, team morale and cohesiveness fear of bailiffs - seen by others at my door pressure on relationships conflict at work family breakdown shame, guilt, stigma social support, friends, family, colleagues

WORK THE ECONOMY "Money and Mental Health will set out the case for employers to provide practical support to employees experiencing financial difficulty, and how this could boost the mental health, wellbeing and resilience of their workforce." "financial fragility" Creditor action poor performance, punctuality, reliability disciplinary action OCCUPATION HEALTH services - counselling / advice Individual's awareness of Rights the hidden economy

Thanks and Acknowledgement to The Money and Mental Health Policy Institute

The Space of Origin - Foucault

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"For us, the human body defines, by natural right, the space of origin and of distribution of disease: a space whose lines, volumes, surfaces, and routes are laid down, in accordance with a now familiar geometry, by the anatomical atlas. But this order of the solid, visible body is only one way—in all likelihood neither the first, nor the most fundamental—in which one spatializes disease. There have been, and will be, other distributions of illness. When will we be able to define the structures that determine, in the secret volume of the body, the course of allergic reactions? Has anyone ever drawn up the specific geometry of a virus diffusion in the thin layer of a segment of tissue? Is the law governing the spatialization of these phenomena to be found in a Euclidean anatomy? After all, one only has to remember that the old theory of sympathies spoke a vocabulary of correspondences, vicinities, and homologies, terms for which the perceived space of anatomy hardly offers a coherent lexicon. Every great thought in the field of pathology lays down a configuration for disease whose spatial requisites are not necessarily those of classical geometry." p.3.

"The exact superposition of the ‘body’ of the disease and the body of the sick man is no more than a historical, temporary datum." p.3.

Foucault, Michel (1973). The Birth of the Clinic. New York: Pantheon Books.

Join the Revolution: For the Lady in the Corner (c/o ST4Health)

ST4Health

INTERPERSONAL : SCIENCES
SOCIOLOGY : POLITICAL

individual

Lady situated assumptions personal experience	one disease - malaria, smallpox, leprosy, TB,  emergency treatment, hospitals, Africa, systems, capacity
people, society, community, village gender, interactions, humanitarian works,	policy, organisations, population health improvement, global health, poverty, economics, outcomes

group - population
BIG PICTURE (above)

My source:  HIFA2015 list