A version of this article will appear in this week's Tribune (out on 25 Feb)
The wildfire of protests across the Middle East and North Africa are clear sign of a thirst for profound change in the Arab world and beyond. They are also a manifestation of a deep yearning for modernity.
The successful intifadas in Tunisia and Egypt already serve as an exemplar to protesters across the region and as far as many Arab youth are concerned, there is no going back. It appears that it is ‘opening the gate of ijtihad’ (the right of independent reasoning) that has been closed to many since the fourteenth century.
Not only is modernity, the aim, it has also been the tool that has underpinned the protests. It is easy to forget that the spark that lit the tinderbox was Wikileaks. US Embassy cables from Tunis laid out the gross avarice of President Ben-Ali’s family and were made public. The people of Tunisia rose up against the depths of corruption the ruling elite had sunk to.
The greatest weakness of Mubarak, Gaddafiet el was the political stasis that they relied on to preserve their power. What was once its greatest strength (i.e. stability) became its greatest weakness.
Apparently unbeknown to their security apparati, a leaderless mass movement had moved beyond a nascent stage and through multifarious networks stood poised to come out onto the streets. .Like all repressive regimes, one of the main aims were always to isolate individuals and deter political intercourse. Up until recently, total control of the media allied to a ubiquitous and intimidating secret police was enough to deter any significant opposition whatsoever.
Facebook, Twitter, YouTube and chat forums created a public space that young Arabs were only to keen to fill.. Politicisation led to organisation which led to demonstrable opposition.
Whist Ben-Ali in Tunisia, Mubarak in Egypt and Gaddafi in Libya had become nepotistic kleptocracies.The tools provided by social media led to the formation of ad hoc political oppositions .Vainglorious narcissists such as Gaddafi were incapable of recognising the deep fissures in their countries and paid the ultimate political price.
The role of satellite television has also been highly important in revealing that there was an alternative narrative to that which was disseminated through the regimes’ official channels. It has served as a crucial source of independent information that has enabled people to access news that could not be controlled by the regimes.
The influence of Al-Jazeera transmissions from their studios in Qatar cannot be underestimated. Untainted by any linkages to western governments, Al-Jazeera has become the trusted source for news across the Arab world and beyond.
The growing disjuncture between oppressor and oppressors went unobserved in the West, whose comfort zone of stability in the Middle East, was epitomised by Tony Blair’s crass comments on Mubarak (immensely courageous and a force for good“). This was an accurate reflection of the west turning a blind eye to demands for democratic change. Oil and Israel have been a potent brew in the Arab world for over 30 years.
It is hugely ironic that two of the current bête noirés of the USA, namely Al-Jazeera and Wikileaks, are two of the crucial pre-cursors of the pan-Arab intifada which will inevitably lead to a much higher degree of democracy in the region.
The Arab world needs now to decide how to move rapidly to democratic governance. A move that must include a role for trade unions and centre-left groups, that seem to have been overlooked as outsiders press for economic reforms without balancing them with the necessary parallel social reforms.
It will be interesting to observe developments outside of the Arab world where other forms of repressive regimes exist. The ruling theocratic clique in Tehran must be sleeping less easily these days and even the ruling party in Beijing might be feeling a twinge of concern.
What the Tories propose for the NHS is utter madness that will only guarantee the worst possible outcome. The proposed reforms will act as a Trojan horse for privatisation. Andrew Lansley's proposal that General Practitioners (GPs) in local surgeries have the strategic responsibility of allocating health care outcomes is also ideologically idiotic.
It is the equivalent of giving the petite bourgeoisie ultimate responsibility for the economy. GPs might claim to protect the NHS, but they are the only segment of the state-provided health care system of in the UK that is not fully integrated into the NHS.
It is also highly likely that once Lansley's plan to have groups of GPs' commissioning all health care for patients then the crucial building blocks of privatisation will be in place.
Of all the major health care professionals' representative bodies, it was only the British Medical Association, representing GPs that opted out of being fully part of the NHS. In 1947 they objected to Anuerin Bevan's proposal for universal health care by a margin of 89% to 11% as they saw it as a threat to their position and income.
Most GP surgeries are still private practices that contract their services to the NHS. Most surgeries are run as separate profit centres with the partners taking a share of the profits. They are paid by the NHS according to the number of people they have registered to their practice.
They remain independent contractors to this day. GPs and their representative body the BMA have always been the most reactionary element of health care in the UK.
In response to Bevan's proposals one former Head of the BMA claimed "I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to National Socialism as practised in Germany. The medical service there was early put under the dictatorship of a 'medical Führer', the Bill will establish the Minister for Health in that capacity."
Most of the staff GPs currently employ are non-unionised and are paid little more than the minimum wage. Even health care professionals such as practice nurses are paid according to how much the practice decides to pay them and not according to NHS pay scales.
There are even differing pay scales between Doctors, with the practice partners employing locum or junior Doctors at a significantly lower pay level than they are paying themselves. In other words, the less the partners in the practice pay in outgoings the more profit there is for them to share.
Therefore, despite GPs attention to detail for certain patients (e.g. those with diabetes, cancer, heart disease) for which they are paid bonuses, most income is predicated on the number of patients on their list and not on how many patients they treat. In fact this situation can be further compounded by partners employing salaried junior doctors to do most of the donkey work, whilst they (as owners of the practice) reduce their own hours.
This has led to a culture whereby managers are employed in many practices to devise ways of providing the minimum of care to their patients. Reception staff are given strict criteria when a patient can see a doctor and those emergency appointments are kept to a minimum number a day. Urgent cases are encouraged to go to NHS Walk-in or Hospital Accident and Emergency departments.
At one surgery in Surrey, the practice partners only work a four-day week (with no evening or weekend working) and each is paid in excess of £100,000 per annum. It is to these people that the Tories propose to hand over almost all decision-making in health care in the UK.
Patients often cannot get to see their Doctors for routine appointments when it suits the patient even if the appointment requested may be weeks in advance. Appointments are often structured so you can’t book well in advance or get emergency appointments at short notice either.
The mantra given at the behest of GP practice managers to harassed frontline staff who often have to face an increasingly angry public is “that people have the right to take time off to see their doctor”, thereby closing down any discussion that Doctors ought to have some form ofservice mentality.
It is legally dubious that people have the right to take time of work to see a doctor and not all employers are as helpful as others and it often leads to workers having to take a holiday to see their GP (if they can get an appointment in the first place).
As the BBC has reported "The plans mean GPs working in groups will be in charge of a vast collection of hospital, mental health and community services" In other words it is they who will make the decisions as to our healthcare. For example, it is they who will decide which hospital we will be sent to for treatment.
Unsurprisingly, the BMA said "they could benefit patients and it was looking forward to working with ministers." This should come as no surprise; however there are real and striking problems with GPs being given such discretionary powers.
A common view amongst some GPs is that “patients need re-educating” in that patients are seen to be too demanding in what they expect. A view often encouraged by the fact that GPs get paid mainly by the size of their patients’ list than by how many patients they actually treat.
Sales Reps from Pharmaceutical companies are already adept at wooing GPs in order for them to prescribe more of the medicines they are trying to push, for example providing generous lunches for doctors’ meetings. The scope for GPs to be offered substantial incentives to favour one hospital/clinic over others will be huge.
Furthermore as part of this privatisation Trojan Horse "Hospitals are to be moved out of the NHS to create a 'vibrant' industry of social enterprises under the proposals." This is yet more 'big society' guff from the Tories, the reality is that hospitals will become profit centres driven by producing shareholder values which will inevitably lead to an antagonistic relationship between health care professionals and finance departments.
If the Tories were really interested in radical reform of the NHS, then it would be the BMA and by extension the GPs who should have the most to worry about. Instead of the subservient relationship we as patients have with our GPs, the reverse should be imposed.
If GPs were paid by the number of patients they see, rather than the number on their list, the dynamic of the relationship between Doctor and patient would be changed overnight. A simple use of a patient's National Insurance number (given to all in the form of a swipe card) or their NHS number would enable state payments to be made to GPs based on productivity.
In many countries in the EU, the Doctor's income level is predicated on the number of patients they can attract to their surgery. This is true for both private and state funded patients. Furthermore the same is true for consultants. The patient doesn't need to have a referral from a GP if they know what's wrong with them (e.g. specific physical injury or the reoccurrence of an already diagnosed condition).
By extension, the same principle should be extended to hospitals and especially the consultants based within them. In what other service provision, would people be expected to turn up in group of 20-30 at a specific time e.g. in order to see an expert, who then randomly allocates whom they see in what order, rather than allotting precise appointment times for each patient?
Hospitals themselves should not be exempted from such reforms. Again, poorly run hospitals with deteriorating health outcomes should not be allowed to continue unperturbed by their failing performance. It is common knowledge amongst many that different hospitals in their area have different reputations. Why should we be sent to a specific hospital by our GP, when most may prefer to go elsewhere?
This would not necessarily lead to redundancies for health professionals, but it would hang the sword of Damocles above management heads. It would be the bosses who would be cleared out not the staff.
There is one other disturbing aspect of what the Tories are trying to do with the Health Service and that is covert privatisation, in a manner that imitates the worst aspect of the health care system in the USA. This is because the system they are planning to introduce gives an opportunity to exploit maximum private profits.
The only discernable rationale to the Tories' changes is that they will be able to convert GPs commissioning groups into Health Maintenance Organisations (HMOs). These private organizations, that were introduced by the Nixon administration in order to drive down costs by limiting access, have a long history of rationing health care for the middle and working classes. They restrict the choice of patients to a few specialists and a very limited choice of hospitals.
In the States groups of GPs, specialists and hospitals band together in a mutually supportive relationship in a HMO. Profits are levered by limiting services to those provided by the HMO and refusing to pay for any service undertaken outside of the HMO's reach unless first approved by the HMO's management. Of course the profits of the organisation are shared by the bodies that make up the HMO.
However, the most disturbing development in the future will be when a private company buys out a GP consortium (with windfall profits for the doctors) and develops a strict policy of vertical integration by only sending patients to hospitals/clinics owned by the same company (or group of companies).
Of, course as part of an inevitable capitalistic development, highly profitable HMOs (i.e. those that can drive down costs as much as possible) have been seen as prime targets for outside investors and many HMOs are now run exclusively for private profit with health care professionals having a submissive relationship to finance departments.
However, the most disturbing development in the future will be when a private company buys out a GP consortium (with windfall profits for the doctors) and develops a strict policy of vertical integration by only sending patients to hospitals/clinics owned by the same company (or group of companies). Ironic if they call it a Health Management Organization. This will be the final nail in the coffin of universal health care in the UK and Lansley's plan will allow it to happen.
It should be the responsibility of the State to fully fund health provision in the UK as set out in the founding principles of the NHS. However, it should not be for the Health Service professionals to decide who is responsible for our treatment. Self-serving interest groups within the medical profession have a long history of preserving their privileged positions. Only by giving citizens the power to make their own decisions will true radical reform of health care in the UK be on offer.
A version of this post was published in Tribune magazine on 11/02/11
By Marjorie Smith
The US's overt policy of keeping Egypt as a pliant State and allowing a brutal dictator to stay in place has directly led to decades of instability in the Middle East. Washington's, and by extension the UK's, foreign policy pragmatism has, in effect, only served to undermine progress in the Middle East by effectively removing from the scene, one of only three key actors in the region.
This pragmatism has also led to Mubarak's 30 year-rule being marked by an almost unparalleled tyranny of the Egyptian people. The recent appointment of the Head of the Security police Omar Suleiman to Vice-President is a ruse to preserve Mubarak's power base. A small elite controls Egyptian society and this reactionary force, a nomenclatura in itself, is desperately fighting to retain its wealth, power and stranglehold over what has been up until now a rigorous hierarchical political and social culture.
Egypt is on the cusp of a social as well as a political revolution. Like in Tunisia, the population has had enough of the old ways. External information sources (plaudits ought to especially go to Al-Jazeera, social media and Wikileaks amongst others) have combined to demonstrate how despotic and kleptocratic many regimes in the Arab world are.
"The three big 'players' in the region, Egypt, Iran and Israel have failed to establish normal relations as an emasculated Egypt has singularly declined to play its part. "
Because of this situation, the Middle East is currently a hotbed of competing strategic interests by nation states that are becoming evermore politically unstable. There is immense dissatisfaction with the varied 'ocracies' in the region, Iran (theocracy), Yemen (theocratic autocracy), Iraq (nascent but fragile democracy), Syria (dynastic autocracy), Egypt (nepotistic kleptocracy) and Saudi Arabia (monarchical autocracy).
The three big 'players' in the region, Egypt, Iran and Israel have failed to establish normal relations as an emasculated Egypt has singularly declined to play its part. Normally, one would expect Egypt to play a pivotal role in the region. It has historically been the leading country in the Arab world and by extension in the Middle East generally.
However, Mubarak's rule has resulted in a dangerous vacuum developing in which a sustainable stability has been unconsciously (?) undermined. The US's blinkered focus on ensuring the security of Israel by neutralising Egypt has allowed Tel Aviv to act with impunity in their interaction with the Palestinians and has allowed Tehran to exert much greater influence than it normally would have hoped to.
It can be argued that the failure of Egypt to authoritatively engage with the Arab world has also allowed disaffection and disunity to take root and contributed to the present day instability. Would Lebanon have descended into civil war if Egypt had played a leadership role? Would Saddam Hussein have dared to invade another Arab neighbour if Egypt had been a confident stable and democratic force in the Arab world?
Iran's backing of Hamas and Hezbollah exemplify its foreign policy objectives for the region. Consequently, Egyptian political impotence has allowed Middle Eastern politics to be seen only through the prism of Israeli security in light of the ambitions of Iran as a regional actor. It serves Tel Aviv well to play up the threat of Iran because it serves its own objectives of keeping Washington onside.
The shameful action of Mubarak and his cronies in collaborating in the siege of Gaza has only led to greater desperation by the Palestinians whilst the Israelis have been able to pretend that they can't negotiate with anybody because no partner can deliver a peace on its own. Egypt's inaction has been Hamas' gain.
It is perverse that massive military aid by the US to Egypt, once Israeli's greatest threat, has bribed a small clique into doing Washington's bidding. A confident, secure Egypt would be a counterbalance to Iranian influence in the region as pan-Arabism (with mainly Sunni Muslim populations) is a more powerful political force than Iran's form of Shia Islam as a unifying force. Egypt is naturally the political and cultural leader of the Arab world and there is very little love lost between the Arabs and Iranians.
Egyptian society is a complex mix of competing forces and the only reason why the Muslim brotherhood became a force is as a direct result of Mubarak's violent repression of any internal opposition. Desperate people were forced into undertaking desperate measures and the brotherhood was able to capitalise on that desperation.
Mubarak has allowed Egypt to be emasculated and that encouraged the re-growth of Palestinian violent reaction over the past 10 years leading to the polarisation of Palestinian politics and the disastrous civil war between Hamas and Fatah.
The Muslim Brotherhood (Ikhwan in Arabic) is not the threat that Mubarak and Israel say it is, it is not a coherent group with a recognisable political ideology but a theocratic movement that does not have majority support in Egypt. Whilst it may gain an influential bloc in any new Parliament, if free and fair elections are held, it is highly unlikely that it would win an outright majority.
The Brotherhood (clearly starting from a low base on gender politics) has been the straw dog of Egyptian politics with Mubarak and his henchmen grossly exaggerating the threat that it posed and labelling it a terrorist organisation In order to leverage large amounts of US military aid which was employed to repress the population as a whole.
Individual acts of terror in Egypt such as the Luxor massacre of 62 tourists at Temple of Hatshepsut in 1997, was conducted by Islamic terrorists from Al-Gama'a al-Islamiyya ("The Islamic Group") and Jihad Talaat al-Fath ("Holy War of the Vanguard of the Conquest").. Neither is or was associated with the Muslim Brotherhood.
Egyptian society is a diverse mixture of all shades of Islam plus Christian and secular forces and like the demonstrations against Mubarak and his cronies has shown, democratic change has huge support. The UK and the EU should disassociate themselves from US policy and encourage a rapid transition to free and fair elections and provide massive aid in order to construct a modern, outward looking civil society with an emphasis on good governance and the rule of law.
If the US really wanted to play a constructive role in the region, it would cut off military aid immediately, switch the funding to providing welfare aid programmes focusing on relieving poverty and financing a rapid expansion in education as well as encouraging a pluralistic political environment in Egypt.
To establish long-term peace in the region a democratic confident Egypt able to negotiate from a position of strength is the best hope for the Middle East. It would also give the Palestinian people a dependable ally whose backing would be able to guarantee equality at the negotiating table with Israel.
It is in Israel's long-term interests to see a sustainable conclusion to the Middle East peace process that can only be achieved if it is underpinned by a free and democratic country that can be the leading force in the Arab world.
Egypt's strategic position in the Middle East has been distorted by internal repression for far too long. It is time it took centre stage again and plays its part in establishing a permanent peace in the region.
Published in Tribune magazine 04/02/11 By Marjorie Smith
The on-going demonstrations in Cairo's streets and squares have shaken the Mubarak regime's foundations. Washington is now on the horns of a dilemma, all of its own making. Yet it looks like it wants to preserve as much as possible of the status quo.
Foreign policy analysts believe that what started as a strategic cold-war decision to wean Egypt away from the Soviet Union's sphere of influence in the 60's became a lynchpin of America's policy of activist globalism. The Arab world's most populous state (by far) is now perceived by many Egyptians as an adjunct of the US State Department.
Even at the beginning of the current crisis Hilary Clinton and the Obama administration's response was widely seen as pathetic, the initial reflex called for stability, i.e. an attempt to shore up Mubarak. Most informed commentators in the Arab world believe that when push comes to shove, the architects of US foreign policy prefer a strong man in thrall to Washington rather than allow the Egyptian people to decide their own future.
Yet Mubarak for the past 12 months has been more concerned about a dynastic succession for his son Gamal, than addressing the profound economic challenges Egypt faces. Most Egyptians believe that the 30 years of brutal repression and what many see as a nepotistic kleptocracy under Mubarak has been consistently indulged by the US.
Driving through the Cairo suburb of Heliopolis, one can see the how the elite in Egypt live. It consists of plush houses, wide avenues, state-of-the-art hospitals, exclusive clubs for the military and others, all surrounding Mubarak's palace. Most Egyptians see it as stark evidence of the ruling class indulging itself in a confident display of conspicuous consumption.
Yet, it seems that despite the rampant cronyism, the control of civilian enterprises by military leaders, the supreme indifference to the worsening conditions of the working classes, the growing lumpen proletariat, Washington would prefer stability to democracy. It is becoming apparent to many that the CIA and others are working on a plan to implement a palace revolution, where Mubarak goes and the elite stay in place, rather than a rapid move to open democracy.
Mubarak's power is entirely based on the support of the military and US indulgence was largely delivered through massive military aid. The large transfers of military resources to Egypt had a multi-faceted role, mainly to keep the military happy and to heavily influence Egyptian foreign policy.
Most Egyptians now believe that since Sadat's peace deal with Israel in 1975, the US has ensured that Egyptian foreign policy is predicated on the interests of Israel. Even now Benjamin Netanyahu is currently scaremongering about how the crisis in Egypt could rapidly escalate to the level it did in Tehran when the Shah was ousted. This is clear evidence of what some commentators see as an attempt by the Israeli tail to wag the American dog.
The continued siege of Gaza, the craven attitude of Mubarak to Tel Aviv's machinations and the longrepression of the Egyptian working class have been and still appear to be central tenets of US foreign policy. Many in the Middle East believe that the repression, the chaos, the anarchy and the numerous dead and injured in Egypt are the direct responsibility of Washington.
Marjorie is a contributor to Tribune Magazine, the premier magazine for debate about politics in the UK from a left perspective.
She was born in Hong Kong of Chinese and English parentage and has lived in the UK for many years.
Marjorie is also on twitter.com under Marjesays
