Baijayanta Mukhopadhyay, A Labour of Liberation. Regina, Saskatchewan: Changing Suns Press, 2016. Paperback, 78 pp., $11.00. ISBN: 978-0-9951551-1-4. 

‘Not all suffering is illness; some suffering is political’.– Baijayanta Mukhopadhyay, A Labour of Liberation

In A Labour of Liberation, it is clear that Mukhopadhyay is passionate about the caring work he does as a physician in clinical practice in hospitals and elsewhere in settler and Indigenous settings in Canada’s North and inner-city Montreal. He is also profoundly disturbed by how this work is organized by the rationalities and priorities of institutionalized medicine. His frustration is palpable in this small-sized gem of a book, which reflects on the organization of these circumstances and the need for change.

A Labour of Liberation is a beautifully crafted and gentle read, fashioned into thirteen short chapters of just a few pages each, andwritten in compelling narrative form to help readers understand the people, places, practices, and politics within. Opening and closing the book with twinned scenes of physician defiance and attentiveness, the author hints at the possibilities and constraints, strength and fragility, of physician agency. An effective rhetorical device used is the author’s questions throughout, posed to himself and his readers. In making the case for the need to do caring work differently, proposing a paradigm shift that reorganizes care within relations and priorities of democracy, equity, and justice, Mukhopadhyay weaves throughout the monograph a radical treatise: formal health systems and institutions are ‘born of injustice, and … breed injustice’ (p. 5). He argues that decentralizing health care and wresting health knowledge from clinical control is necessary if we want to deliver on the promise of doing and receiving care in ways that serve emancipatory ends. In this polemic, Mukhopadhyay declares that this ‘labour of liberation’ requires changing the prevailing social and power relations (Smith 2006) that organize health care. If carers were to commit to this effort, he maintains, they would work themselves ‘out of a job’ (p. 5).

Caring work = Transforming how health knowledge is organized

The chapters offer deeply reflexive, interdisciplinary, empirical, historically situated, theoretically rich, and politically provocative exploration and critique of the social organization of caring practices within and beyond contemporary biomedical institutions. In so doing, Mukhopadhyay elaborates on the joys, struggles, and contradictions that have shaped his care work, as well as that of his colleagues and patients. We enter corridors, exam rooms, and other physician workspaces, and observe vivid scenes of interactions and working conditions in these spaces. The reader meets various people and learns of the ups and downs they, including the author, experience in situations of care. A Labour of Liberation will sit on my shelf in the company of its kin: Timothy Diamond’s Making Grey Gold (1992) and Making Care Visible (2002) by the working group of the same name.

Broadly, the book is structured in a back-and-forth fashion, with most odd-numbered chapters exploring the logics that govern care and most even-numbered chapters considering how caregivers come to think, learn, teach, and practice. Chapter 1 produces new understandings about how the work of caring within health systems is linked to other such work done by others, elsewhere. Chapter 2 focuses on power relations that organize professional training. What sorts of social processes and practices have we not been trained to see, and how have these distanced or alienated caregivers from caring? Offered here is a situated critique of the ‘perversity of ultra-specialisation in medicine’ (p. 12). Chapter 3 focuses on the dominant paradigm of financial reasoning within for-profit institutions, and how this shifts attention from the kind of caring ‘work that might be most valued by the sick’ (p. 16). Here, the author argues for listening to people and hearing what works for them.

Chapter 4 ponders how the epistemological and ontological paradigms within which we carry out our lives inform and shape caring work. The reader is asked to consider how hierarchies are reflected and refracted through social class, education, patriarchy, paternalism, gender, divisions of labour, ‘pomposity’ (p. 31), and professional title, among others. Chapter 5 considers interconnections among relations of care, authority, and social control. The author’s cards are on the table: health and health care are political. We are guided toward a ‘social autopsy’ (Klinenberg 1999), in which social norms, arrangements, and representational regimes are the objects of analysis and the problems these produce are pathologized.

Chapter 6 addresses who and what is involved in developing the skills and competencies to care. Mukhopadhyay argues that apprenticeship, mentoring, and training can ‘come from surprising corners’ (p. 28), and reminds readers that ‘everyone becomes a health worker at some point in their life’ (p. 29) via actions big and small. I take this chapter as an expression of gratitude to the people Mukhopadhyay has cared for, who have helped him understand that to do such work well requires both compassion and critique. Chapter 7 uncovers connections among biomedicine, state rule, and the profit motive. Through the example of the British colonial project in India, Mukhopadhyay explores how social class and the mobility of Indian physicians were used to embed them in colonial practices that displaced and delegitimized nonbiomedical forms of knowledge.

Some chapters include the perspectives of allied professionals, such as nurses and social workers, whose caring practices are shown to both produce liberating and oppressive effects for them and others. Chapter 8 covers medicine’s rush to intervene, with Mukhopadhyay declaring: ‘I want to unlearn the instinct to intervene, and instead to learn the duty of listening, in accompaniment with suffering’ (p. 63). Chapter 9 addresses unintended consequences of institutionalized caring practices, challenging readers to see this work as fraught with difficult ethical, moral, and material tensions and contradictions that are at times impossible to reconcile (Bisaillon 2014). When activists work, for example, to increase access to health care, they facilitate the ‘penetration of profitable industries even further into a captive populace’ (p. 34). Turning to activism and the caring work of women, chapter 10 draws inspiration from mid-twentieth-century strikes by women caregivers in Quebec. Their mobilization was vital within a larger solidarity movement that triggered a massive social shift culminating in the 1960s with Quebec’s Quiet Revolution. Chapter 11 then turns to the politics organizing the practice of social work. Academic and practitioner social workers have long wrestled with tensions stemming from role conflicts, for example, in creating ‘liberatory frameworks’ (p. 53).

Finally, chapter 12 invites the reader to stand beside people they care for and care about, and to listen to ‘how people understand their own health’ (p. 58). Here, the author clarifies his frustration with how bureaucratic and specialist logics ‘succeed in making health such an inscrutably technical field … that we have forgotten how fundamentally political our well-being is at its core’ (p. 57).

A manifesto to rethink the work of caring

Mukhopadhyay charges that dominant approaches in current health research, education, and practice are guided by positivism, reductionism, and biomedical knowledge, and that these stifle other forms of knowing, including our everyday knowledge about our living conditions. In this way, the book is a manifesto calling for radical transformation in how we think about the work of caring and how this work is done. Mukhopadhyay explicitly recognizes that his ‘political health work’ (p. 57), as leader, organizer, and activist in health justice outside of clinical practice, is deeply informed by the inequities embedded withinit. He envisions a workforce capable of identifying, problematizing, and developing understandings about social and power relations that organize what we say and do in the name of care, and the consequences of this. He calls for readers to acknowledge their social positions and to recover ways of knowing outside of the biomedical lens. This requires conceptualizing ourselves as carers, recognizing the various forms of care we do every day in the service of self or other.

A Labour of Liberation contributes to various subfields of the social sciences and humanities, and in particular critical approaches in anthropology, history, political studies, social work, and sociology, as well as narrative medicine. As such, it is refreshingly exemplary of interdisciplinary praxis. It seems the fruit of what happens when, instead of prioritizing methodological or lofty theoretical aims, an author thinks big, and in so doing, mobilizes a diverse wealth of knowledge for committed social analysis in the spirit of stimulating dialogue.

I chose this book as one of four to be read by second-year undergraduate students in my Introduction to the Social Determinants of Health course (fall 2017). Students were asked to reflect on Mukhopadhyay’s ideas and how they relate to the circumstances of their lives. Together we explored the author’s claim that ‘not all suffering is illness; some suffering is political’ (p. 23).I will continue to engage my students in this journey, particularly because many aspire to careers in clinical health, health policy, and health programs. As a complement to the ideas presented in the book, a two-part audio interview with the author is available online (RankandFile.ca 2016). Beyond those in higher education contexts, I recommend this book to anyone from their early teens to later in life, and hope it will be translated into many languages for wide distribution.

About the author

Laura Bisaillon is an interdisciplinary social scientist and assistant professor in the Social Justice Education Department and the Interdisciplinary Centre for Health and Society at the University of Toronto, Canada. Troubled by how socially arising inequities press bluntly on people experiencing marginality, she explores the politics of knowledge production to generate work that can be used to correct, resist, and transform. Her academic website is: http://www.utsc.utoronto.ca/healthstudies/laura-bisaillon

References

Bisaillon, Laura. 2014. ‘Introduction: The Politics of Practice and the Contradictions for People, Policy Providing Care: Investigations into the Implications of Health Work Organized within State Interests’. Public Health Ethics 7 (3): 225–28. https://doi.org/10.1093/phe/phu037.

Diamond, Timothy. 1992. Making Grey Gold: Narratives of Nursing Home Care. Chicago: University of Chicago Press.

Klinenberg, Eric. 1999. ‘Denaturalizing Disaster: A Social Autopsy of the 1995 Chicago Heat Wave’. Theory and Society 28: 239–95.

Making Care Visible Working Group. 2002. Making Care Visible: Antiretroviral Therapy and the Health Work of People Living with HIV/AIDS. Toronto: Making Care Visible Working Group. http://chodarr.org/node/1451.

Rankandfile.ca. 2016. ‘“A Labour of Liberation”: An Interview with Author Baijayanta Mukhopadhyay, Part 1’. Rankandfile.ca, 21 July. http://rankandfile.ca/2016/07/21/the-labour-of-liberation-an-interview-with-author-baijayanta-mukhopadhyay-part-1/.

Smith, Dorothy, ed. 2006. Institutional Ethnography as Practice. Oxford: Rowman & Littlefield.