Apocalypse and change. With GP Andy Knox

“Change can happen. Change has happened…”

Poverty makes us unwell. GP Andy Knox sees this in his North Lancashire consulting room, meeting people whose lives could improve if stigma and destitution went away. He tells sociologist Imogen Tyler about the burnout facing doctors and frontline workers trying to care for their communities on scant resources, and reflects on how we need to ask “bigger deeper questions” about what’s making our society sick.

But, inspired by Rebecca Solnit’s idea of hope as an “axe” – as something to practice, actively – Andy says change can happen if we have the humility to listen and the audacity to act differently. Describing working alongside his area’s Gypsy, Roma and Traveller community, he shows how listening can be an anti-stigma practice, and also reflects on the power of social movements. We must not scoff, he says, at “being woke” – indeed, in this time of “apocalypse” and revelation, refusing to “wake up” is not an option.

Note: **In this episode, Andy mentioned suicide rates among female GPs. For recent research on this, see Claire Gerada's work in the British Journal of General Practice. 

Credits

Host: Imogen Tyler
Guest: Andy Knox
Executive & Development Producer: Alice Bloch
Project Lead: Imogen Tyler
Project Officer: Danielle Galway
Sound Engineer: David Crackles
Music & Artwork: Bruce Bennett

Episode resources

• Andy Knox’s forthcoming book Sick Society (2023)
• Hope in the Dark Rebecca Solnit (2004)
• The dictionary of alternatives utopianism and organisation Martin Parker, Fournier, ValeÌrie & Patrick Reedy (2010) 
• Poet, writer, activist Dionne Brand receives her honorary degree (2018)
• Doughnut economics : seven ways to think like a 21st century economist Kate Raworth (2017)
• The work of Katherine Trebeck 
• The value of everything: making and taking in the global economy Marina Mazzucato (2018)
• Learning from the Sixties A lecture by Audre Lorde lecture (1982)
• Andy Knox’s blog at The King’s Fund  
• Martin Luther King, Jr. Papers Project

Find extended reading lists and learn more about The Stigma Conversations at  The Sociological Review 

Act!

Trussell Trust
Independent Food Aid Network
Enough is Enough
Disabled People Against Cuts
Everydoctor
Healing Justice
Shelter
Southall Black Sisters
The Peoples Assembly
Acorn 

Transcript

Imogen Tyler: 0:06

Welcome back to the Stigma Conversations with me, Imogen Tyler. By now you'll know why I want to talk about stigma, even when there are so many conversations going on out there that are doing great work to break down boundaries and taboos. Stigma is dehumanising, divisive, places limits on our lives, and talking about how that makes us feel really matters. But if we're to change things at the structural level, we need to also really talk about the big picture – to ask how stigmas produced and why, if we can do that – daring to look up and back at power, at history– we can see how stigma is entangled in bigger systems politics, economics, capitalism, colonialism, patriarchy. When we do that, we get a new way of seeing basically, we begin to recognise stigma as a power of practice and machine – something orchestrated to serve the powerful – and then we can stop blaming ourselves or thinking"that's just how things are" and we can ask for better. In this series, I've been meeting academics, activists and frontline workers, to help me do just that, to reflect – not only on how stigma works and where it comes from – but how we might, in fact, must move forward. Last time, we heard Geraldine and Jasmine from Lancaster Black History group, talking about working to fight racism through education. Something that stayed with me was Geraldine's line on how to take on racism – we have to engage people in the conversation, to collaborate to improve racial literacy, and get rid of the shame of ignorance. Only then can we challenge racism and white privilege. To today, I want to continue thinking about social change, and how that takes really considered engagement with communities. I first met the GP Andy Knox through our work on the same local Poverty Truth Commission, where I met Helen Greatorex, who you heard from earlier in this series. As well as being a doctor here in Lancashire and a dad, Andy's an Associate Medical Director for Lancashire and South Cumbria. He's also an associate at the King's Fund, where he focuses on population health and health inequalities. We spoke back in November about the crisis in the NHS, and how stigma makes us sick, but also about hope and change. Andy described the knock on effects of things like austerity and cuts on society's most vulnerable people.

Andy Knox: 3:00

We have a term that I really don't like – but I hear a lot of my colleagues talk about– which is "shit life syndrome". And the reality is that a lot of people come to us simply to say, my life's terrible, and I don't know what to do about it. And a lot of the physical and mental health stresses that they are experiencing, are actually directly related to, to poverty– and to a lack of ability to participate in life, and to have positive choices available for them. And it's a really harrowing experience, actually, as a clinician, or as a GP – who really loves and wants to serve your community – to feel quite helpless to feel like you're sitting and you're listening, and you're, you're holding someone's pain with them. And most of your training, you're taught to try and fix people, or to try and offer some solution or to offer some hope, or some other bits and pieces. And the problem is that we've developed some kind of narrative around poverty that there's deserving poor and there's undeserving poor. And actually, most people are kind of poor, because they're lazy, or they're feckless, or they're wasters or they're, they've done something wrong somehow. And yet, you hear story after story after story of people who have experienced major social injustice and actually don't have this sense of great choice available to them. And they're coming to you saying – What can I do? And you increasingly in response are saying – I actually don't know apart from just hold your pain with you and commiserate with you that actually life is really tough. And we are seeing an exponential rise in the prescription of antidepressants, of anti-anxiety drugs have been referrals through to mental health services – which are overwhelmed with the referral processes and cannot keep up with the demand that has been thrown at them through primary care. And what's left in primary care is clinicians holding incredible amounts of risk. Because the services that could be there to support people are no longer there. And that's a really distressing experience, actually, as a clinician who's genuinely sat there trying to help work with your patient for solutions around things that really matter to them.

Imogen Tyler: 5:31

I'm actually, you know, I feel quite upset, listening to you speak – I mean, upset and actually angry. And I think – as you know – one of the things I've written about is how that kind of top down stigma, that kind of culture of blame, you know, was such a big part of the austerity project and the broader sort of social and cultural sense. And the sort of disconnect between the social suffering that you're describing, and that people working on the frontline – like you – are having to face and deal with – and that kind of just totally vicious, divisive politics of blaming people in poverty for their poverty – I just find that deeply upsetting and angering. It just feels like, you know, the point where you think it can't get any worse, it get, it gets worse, and it is getting worse in this sort of winter period that we're in. And I just don't – I suppose it's not really a question, I just don't know how people in your roles are able to cope with the stress of everybody else's stress. So I just want to sort of acknowledge that, really,

Andy Knox: 6:57

Thank you. And we do see really high levels of burnout and stress, we know that, you know, we've had some very, very sad cases recently of GPS committing suicide, nationally. And for women, the highest suicide rate professionally, is to be a GP. That's a really staggering statistic, isn't it, but actually, the strain – and then the blame also of GPS on– you're not working hard enough, you're not looking after all of these people, you're not making yourselves available enough, you're waiting times are too long. But when everything else has been cut around you – all the stuff that used to help people and people are pouring through your doors, like a tidal wave begging for help – and you're working every hour you possibly can to provide this kind of care. And then being told through many parts of the media – this isn't good enough, you're not you're not caring enough, you're not doing enough– you can understand why people are burning out, leaving, retiring early, saying, I'm done with this, you know, I've poured my life out for the sake of this community. And now you're telling me everything I'm doing isn't good enough, when everything else that used to be here to support this community isn't there anymore?

Imogen Tyler: 8:05

Yeah. And I've been thinking recently, you know, since I wrote the stigma book and the machine – and I have, you know, a lot of focus on things like the welfare and benefits stigma. But I think there's been a sort of ex... a sort of huge increase in sort of, the same sort of stigma politics – I think the whole woke narratives are kind... is basically a stigma politics – and it starts to scoop up other people and groups including people who work in the frontlines of services – who start being stigmatised by the these sort of narratives. It's sort of like an explosion of the sort of machine. I mean, one thing that would be interesting, just to mention, I think – is the work, that well we did some work together when we worked on the local Poverty Truth Commission – but also something more hopeful, I guess, than what we've talked about so far – which is how the work we did, which was separate pieces of work – but the work we did around our local gypsy traveller community – actually did lead to sort of change. Do you want to tell us a little bit about that? Because I think, actually one of the travellers that you know, that we worked with, rang me up the other day, and I had – it was such a light smashing conversation that I had. And she kind of reminded me about what a huge impact being part of that process of sort of grassroots activism on the ground that we're involved in, had on her life and the life of her community. So that that I found that very helpful moment. So I wanted and I know you've done this incredible piece of work around health and that community– which is just such a stigmatised community – it'd be good to hear you talk about that.

Andy Knox: 10:00

Yeah, I think the Gypsy Roma Traveller community are one of the most stigmatised communities in the country by, by a long way. As a tiny bit of background into this – I think I really like what Rebecca says about hope – which is that hope is an axe. Hope isn't some way you just sit away and kind of cross your fingers and, and dream of a better life Hope is what you do in an emergency situation, where you take an axe to the door, and you get out of the fire, and you begin to you know, break free into something new. And I think there is real hope for people working in Primary Care, for people working in different frontline services right now. But it isn't from staying in where we are and continuing to work in the same ways and always just feeling this sense of overwhelm. There is something about having the, both the humility and the audacity and the hope to step outside of the four walls of how we normally work – and choose to go and be with our communities differently, to listen to them at a much deeper level. And to find out actually, that some of the services we think we're providing for good are not really what our community need – and we're all feeling overwhelmed. They're feeling disappointed. We're feeling burnt out. But actually if we learn to listen at a totally different level, we find co– compassion. And we begin to think and work together differently. So very briefly – on Gypsy Roma travellers – one of the things that we discovered was that women in Lancaster were dying 20 years earlier from breast and cervical cancer than any other women in the city. So we began to – through the Poverty Truth Commission – sit with Gypsy Roma traveller communities, on their turf, at their invitation. And we began to hear the truth of what it feels like to be a Gypsy Roma traveller in our area. And we learned some staggering things. First of all, we learned that we thought there were only 1000 gypsy Roma travellers in Lancaster and Morecambe. The Gypsy Roma traveller community tell us there's more than 10,000– 9000 of them never even get to admit to being Gypsy Roma travellers because of the kind of stigmatisation and racism they experienced – even at the front doors of our GP surgeries. The eye rolling the tut's, the little giggles to the person next to them. The second thing we learned was that because of really high illiteracy rates, actually amongst Gypsy Roma traveller women – our traditional ways of trying to reach out to them – sending leaflets to invite them to breast and cervical screening services were completely culturally inappropriate. In fact, they were potentially racist. And so we had to learn that we're if we're gonna, if we're serious about working in this community, we better find different and better ways of working with them. The third thing we found out was that culturally, Gypsy Roma traveller women won't talk about breast or gynae issues in front of their male partners or in front of a male clinician. So we're providing clinics with male doctors in, or male nurses – or they've got their partner with them – they're not going to admit to the fact they've got a breast lump or a funny discharge. And so then they're getting really significant cancers – which are presenting much later with far worse outcomes. So once we began to understood this, and we could share the information with them, it began to radically transform the way that we work together. So now we've got these amazing champions within the community who are working with us to spread the message about why screening is so important – but together with them, we've completely redesigned the way we deliver clinics, where we do deliver them, how we deliver them. And I think that over the next five years, we'll be able to close that health inequality gap – which has been meted out to them – through inappropriate practice, and through a lack of engagement or through a lack of care. I think it's not because people didn't care. It's just that we didn't know how to care because there was such stigmatisation and barriers that had been created. And by breaking those down and choosing to listen differently – with a sense of humility – we've built a different kind of relationship, which is full of hope.

Imogen Tyler: 14:04

Yeah, I mean, it's just such a profound example. And I'm reflecting as you talk, on what I learned from you – and others as part of the Poverty Truth movement – about reflecting on your own positionality. I mean, we call it in the Poverty Truth, something like – you see, I see, we see – and the and the goal, and it's always temporary, and there's always power. But the goal is that – the you and the I, the them and the us can somehow see something as a "we". But it involves this process of having to do some quite serious and continual reflection on your own positionality or that's what we call in sociology, let's call it. But you use the term"humility" a lot when you describe that self reflection. And I wondered if you want to say something about how that works for you. How you come from your background – which is pretty privileged – and then how do you work continuously to challenge your own positionality in a way that allows you to do that, to break down those "them and us" in your in your practices.

Andy Knox: 15:15

So I think that humility is the starting place for any relationship – that sense of being willing to unknow. And therefore actually have a fascination and a compassion in the other person – that you don't get to assume or to know about the other person's experience because you don't walk in their shoes, you don't know their life or their story. And so actually having a fascination in people and being willing to put aside your assumptions is a really, really important starting place. But I think for me – I don't think I would be this way if it wasn't for a really lovely Kenyan man who I went and spent time with my gap year. Truth is that I come from a really privileged background, went to a very nice private school, from a very upper middle class family. And I went and took my gap year in a place called Bungoma, in Kenya. And I came with an enormous amount of white privilege, colonial attitude – which I didn't even know was in there. Just ways of seeing the world that were phenomenally arrogant and, and naive. And I remember this lovely man – who was the Bishop of Bungoma, he actually became the Archbishop of Kenya eventually, Eliud Wabukala, and one day, he just put his arm around my shoulder, he said, Andrew, let me take you on a walk, and let me just share with you life here in Kenya. He knew exactly what he was doing. But like a father figure to me – he was deliberately opening my eyes and provoking me to see the world differently – and helped me to understand the effects of colonialism, Britishness – all this kind of stuff in a completely new light – with such humility with such grace, and it changed me it genuinely changed me. And I came back with massive culture shock, but determined that I needed to learn to see differently and to be differently in the world. And I think that we all need those wake up moments. I will wear the badge "woke" with pride. I want to be woke. My goodness me, why the hell would you want to not be woke? Why wouldn't you want to be awake to the issues of injustice in the world? Why would you not want to have your heart and your mind changed to the realities of stigmatisation and its effects in society? It's disgraceful that we should mock it. It isn't anything to be mocked – if we're not afraid to be woken up from our sleep, about the level of injustice in society – we should be ashamed of ourselves. It's not something to be mocked, it's something to be celebrated. And I will wear that badge and I will wear it with pride.

Imogen Tyler: 17:53

I'll join you in what in wearing that badge. And I think what you're describing around thinking about your own positionality – about being awake, being alert – and I write about this a bit in the book – using the poet Dionne Brand – to talk about a shimmering alertness. And that really reminds me of this – what you're saying in this conversation – this being alert and awake to histories of oppression. And to kind of current stigma politics in a way. This are the sort of anti stigma, practices that we're talking about that we need to engage in. And being awake to stigma is part of that process. I'd like to ask you about your writing. Because I know that during the pandemic, you started writing a book of your own called "Sick Society". But tell me about the book and why I mean– it's phenomenal you've found time to write it. I know that was a challenge from conversations that we had at the time. And I think it's brilliant that you have, because I think this wisdom that you've got needs to be in the world and shared. And people will learn a lot from it. So tell me a little bit – I know it's not coming out yet. But tell me a little bit about the book and how it... why you wrote it and how it works?

Andy Knox: 19:15

Yeah, well, I wrote it because I think as a dad, and as a doctor, I'm so fed up of this feeling of overwhelm. And the huge issues – that my kids are talking about, and their friends are talking about – that we're just not taking seriously enough. So the issues of poverty, the issues of climate change, the issues that are leading to such division within our society. And it made me kind of reflect that over the last 18 years of my medical practice, that I have met so many people who have come to me wanting help or looking for a solution to their problems. And actually the diagnosis is not that there's some something easily fixable that I can just put a plaster over. There... if we've, if we walk out with these people into society, into community, we find deeper structural issues in society that are making them unwell. And so "Sick Society" is to say, many of the people coming through the doors of the NHS and through the doors of social care. through the doors of our criminal justice system – they're not unwell because of bad choices they've made and also the solution to their problems are not, let's just put a sticky plaster on or a bit of cream here and out they go or give them an antidepressant – we've got to ask bigger, deeper, better questions about the sickness within our society. Our society is sick, it is more divided than it's ever been. It is in a real big mess in so many ways. Women in our poorest communities are dying earlier than they have been, for the first time since the Second World War. We've got some really deep ingrained issues. And 78,000 children in our care system now. There's some stuff in our society that's just deeply troubling. And so what my book does is it says – so if we're going to take a societal view of these issues– what is it that we might need to change? And it really gets to the core values on which we build our politics and our economics – and asks if we were to actually choose love and kindness, and compassion, as kind of core foundations of how we might reimagine a society together – in terms of how we relate to the ecology, how we relate to each other within communities – what might the world be like? I want us to explore those themes – because we are on some kind of highway to hell, in terms of climate change, and societal breakdown – and we need to find a new and better way together.

Imogen Tyler: 21:55

Totally agree. And I think the reason I agree is partly because I've been able to work with people like you, you know. And I think when I first met you, you know, you started talking about love – and I'm like, oh, that's a bit, you know– for us cynical academics – we don't talk about things like love, or we think it's a bit wishy washy or a bit... But actually you mean something more than that – you're talking about a shift in values, you know, a shift in, that actually – as you say impacts not, you know, it's social values, but it's also economic – the way we think about economic value or value in economic only terms. It's a whole, it's the whole piece that has to shift. And I guess what we've been trying to talk about in the in this episode is about how forms of solidarity and you know – we can call them love, and we can call it kindness, and we can call it friendship – or how forms of solidarity have to emerge – where people in different positions of power can ally themselves with others. And solidarity is also a word that gets chucked around a lot. What's it mean, or there's a kind of political sort of image that springs to mind, of a certain kind. But I think what you mean or what we've kind of experienced in different forms by solidarity – is about that kind of humility, the self reflection, it's about a solidarity that is... it's a continual practice. It's not, it's not an abstract thing – it's a continual practice, of checking yourself listening, make, putting yourself out with, with people,

Andy Knox: 23:43

If you use the word solidarity, I would use the word quite simply friendship – I think a society of friends. So I really love the Quaker movement. I'm not a Quaker, but I've got a lot of people around me who are and I love, you know, some of the founding principles of Quakerism. So they talk about radical wonder – a real sense of awe in the world that we live in, and the beauty of people and the world. It's like have a sense of wonder. The second thing is radical justice. And the third is radical friendship– and I think they're not bad principles on which to try and build a society together – a Society of Friends is another name for the Quakers. And I think there is something so beautiful about friendship across difference because it changes us.

Imogen Tyler: 24:29

We talked about the local – our own work, our own practices, your practices, the challenges. How do you how do we connect those forms of social solidarity and activism that we do locally to more horizontal social movements, bigger, national, and indeed, global? Thinking about the ecological global level change? Yeah, how do we do that – have we just got the local at the moment because we're surviving through a crisis, but or is there some way to connect the local solidarities to bigger social movements?

Andy Knox: 25:16

I think social movement is what changes society. So if we look back over the last 150 years – and you think about the suffragette movement, and women's votes and women's rights, if we think about the civil rights movement in the US, and how that's begun to impact around racial equality– that we have still got so much work to do on both of those. LGBTQ plus rights, again – still so much work to do – but what a movement in terms of change globally already. Thinking about now Enough is Enough, or the climate change movement. You know, there are, there are some really key lessons for us to learn from these movements in terms of how we join things up, how we do build relationships, how we – rather than compete actually join forces together. Things have changed in society because of social movements. And they will change more as we join things together – and actually put our own weight and passion into them as well. I think, alongside that, then you have to think about government, government and policy and especially funding – the funding formulas that need to shift towards areas of real change. And that's why I think some of the great feminist economists at the moment – like Kate Raworth, like Katherine Trebek, like Mariana Mazzucato – we need to pay attention to people who are speaking into this space, and be willing to find new ways of doing things together. To fail early, to try again, to work out why things didn't quite work, and to go again. And that's where movement begins to happen. But then also, we need to draw on the kind of wisdom that says– but who are the real change makers within our communities? We need people who are long in the tooth, who are really committed to communities and who are going to be there long term– we need people who are going to be the agents of change in irritation. And we need people who are then going to watch over relationships and care for communities, as social change begins to happen so that it doesn't become divisive, or competitive, or adversary. It becomes collaborative and kind and conducive to the kind of societies that we want to build together. So keeping a strong sense of vision – within the social movements for the societal change that we want to see – I think is absolutely vital. And there's so much great work that's gone on around social movements, and, and that's why I think we should still keep hope alive – change can happen, change has happened. And we are at, I would say, an apocalyptic moment. That means things have been revealed for what they're truly like. Apocalypse simply means "to reveal". So what is being revealed right now? Massive societal injustice, unbelievable destruction to the climate. And so now is the exact moment in which the fulcrum turns – now is the moment to draw the line in the sand and say, things have to change. And so when we feel that sense of impetus – when we feel things beginning to shift and turn – that's when we begin to feel the hope and the energy to create the future that in our hearts we really believe is possible.

Imogen Tyler: 28:30

Andy. it's been absolutely fantastic listening to you and talking to you – and it's good to end with hope. Thank you so much. I can't imagine how anyone hearing today's conversation could conclude that we're in anything other than a state of emergency. And as we're approaching the close of the series for now, I wanted to say a few extra words – a bit of an essay, I guess. In 1982, the American writer and civil rights activist Audrey Lorde, gave a lecture called"Learning from the Sixties" as part of an event celebrating Malcolm X. She said in that, that in each of us, there's a piece of humaneness that knows we're not being served by the machine – which orchestrates crisis after crisis – and is grinding all our futures into dust. She went on to talk about how – if we're to keep at bay, the forces that work to oppress us – we must recognise that attack against one of us is an attack on all of us, who recognise that our interests aren't being served by the current systems. In recent decades, we've seen new tactics and strategies of machine breaking emerge, to take on the stigma machines that shape our world – from environmental protesters who lock themselves into vehicles and buildings and deface paintings – to the disability rights protesters who use their wheelchairs as weapons to block government buildings, who hold die-in protests against changes to medical, health and social care. The hackers who expose the innards of the machines seeding white supremacist ideologies across the world. Now the challenge is how to unite these very diverse and intertwined struggles for freedom – in order to forge solidarities to break the machines that are – to use Lorde's words – grinding our futures into dust. If you want to read more about stigma and do something after hearing these conversations, there are loads of resources you can access – my book "Stigma", yes – but actually loads of community groups and movements like the ones we've raised in these episodes. We'll share a load of resources in our episode notes and at this shows section on the podcast page of thesociologicalreview.org. Please also, of course, share this series far and wide. When I was speaking with Andy about feeling woke and being awake, it made me reflect on how woken up and invigorated I felt making this series. It's really inspired me to stay awake to stigma. And remember, stigma is always there in some guise – but we can fight it too. My producer was Alice Bloch. And the sound engineer was Dave Crackles, Thanks for listening to the Stigma Conversations.