Chapter II Three Stages in the Medicalisation of Deviance

The Chronic Patients

The resident population of chronic hospitals fall into two main categories:

l. a large group of elderly infirm (geriatric) usually defined as aged 65+, and a small group of younger severely physically impaired people.

2.the mentally disordered. The 19th century labelled these people lunatics and idiots. The 1959 Mental Health Act specifies four categories, briefly:

  1. the mentally ill (undefined, but including psycho-geriatric patients)
  2. the severely subnormal (who may also have physical impairments)
  3. the subnormal
  4. those with psychopathic disorder (sometimes called personality disorders)

The Royal Commission on the Law Relating to Mental Illness and Mental Deficiency, 1954-7, preceding the Act, stated quite clearly, “Disorders of the mind are illnesses which need medical treatment.”  Thus, the reason for admission to hospital is ostensibly an illness necessitating medical treatment which will alleviate symptoms, if not cure.

However in many instances, admission and retention is primarily for social reasons. For the elderly, there may be lack of relatives to provide support, often combined with inadequate  housing  or insufficient Local Authority services. Admission to an acute medical or surgical bed implies relatively rapid discharge. A moral rule is not to block beds in which consultants have a proprietorial interest. A selective process based on age, imputed prognosis and social circumstances, rather than medical condition determines placement.  This operates like processes observed by Sudnou.  Aspects of social structure and procedural activities define patient categories as acute or chronic, but allocation to geriatric or psychiatric wards depends more on bed availability than classification.

The behaviour of mentally disordered, young and old, has broken moral rules and expectations, their deviance needs control as well as treatment. Possessing attributes or displaying behaviours which are unacceptable to significant others, they pose a problem about which ‘something ought to be done’. At the turn of the century some females were categorised as morally defective and mentally deficient, having given birth to an illegitimate child. Promiscuity, for girls, is still likely to lead, albeit indirectly via court proceedings, placement in care, absconding and the perceived need for secure placement, to psychiatric hospital, including the special prison hospitals. A recently reported case concerns a man, now 87, who had the misfortune of being born in the workhouse. The illegitimate son of an illegitimate mother, also born in the workhouse, given no formal schooling, was ‘naturally’ assumed congenitally feeble minded. Being physically fit, he proved useful working within the hospital. It says much for his stamina and persistence, and the current trend to decarceration, that after years of trying to shed his inmate status, he was released in 1980.

Except for the multiply-impaired (2.b. above) the mentally disordered range from being considered a nuisance to others, being vagrant or alcoholic; in need of care and protection against exploitation and physical, including sexual, abuse; a danger to oneself, being incompetent; to a threat to the safety of others because of “dangerous, violent or criminal propensities.”  The latter are likely to be confined via court order in one of the special hospitals. A majority sectioned (s.60) and detained under the 1959 Act, with a restriction order (s.65) cannot be released without Home Secretary’s approval.

Are these socially troublesome people, who are also often considered economically non-productive, really sick? If so, how can one explain why Home Office rather than DHSS has jurisdiction over the last category? To understand why some kinds of socially deviant behaviours are perceived as illness, others as badness (criminal or sinful) whilst others are a mixture of the two, we must consider the processes of social control and the medicalisation of deviance paralleling the development of psychiatry.

Social Control and the Medicalisation of Deviance

The aetiology of infectious diseases, first understood in the late 19th century, is the basis of the dominant paradigm of medical knowledge and practice. Non-infectious conditions are comprehended in a similar positivist and commonsense way.  Whatever the ‘disease’, it represents a deviance from some perceived norm of ‘health’ in a given culture, whose recognition causes the affected person to define himself or be defined by others as ill.

Any illness can be defined as social deviance believed to have a bio-physical cause, requiring bio-physical treatment which has become “the licensed domain of the medical profession”   in industrialised societies. What is perceived as illness has social consequences whether or not it has bio-physical causes. When illness is perceived as social deviance it is desirable that like infections, it should be treated to ameliorate or cure, and be controlled and prevented.

Prevention of the spread of infections has been successfully accomplished by public health, environmental controls and immunization. Prevention of other diseases has been somewhat neglected until recently. However medical advice and informat­ion is a growing factor in influencing life styles. Extension of the practice of medicine into daily life, and application of the labels ‘healthy’ and ‘ill’ (as) relevant to an ever increasing part of human existence” is known as medicalisation.

Social control exercised by doctors is not perceived at commonsense level, which focusses on the cure and care of the patient. Doctors’ Aesculapian authority, sapiental, moral and charismatic, allows the patient to make his total self available for examination, treatment and control.   Implicit in  Parson’s conceptualisation of the sick role  is the fact that the Doctor legitimates his changed status through the process of diagnosis. Should the doctor consider nothing is wrong, the person – regardless of how he feels – is not ill and has no disease. If diagnosed ill, he is not held morally responsible for his condition and is excused from fulfilling his usual obligations. He is obligated to cooperate with medical experts, and must relinquish the sick role when his functional health is restored or risk being labelled another kind of deviant – malingerer or neurotic.

Whilst this version of the sick role has been modified and criticised, being inappropriate for chronic conditions, the medical profession have become the dominant agents of control, regardless whether cure or amelioration is available, for anything that can be considered illness. Much behaviour perceived as social deviance is now so considered.

Medicalisation of deviance is part of the larger extension of medical practice and ideology to everyday life. Although apparently morally neutral and objective, as befitting the application of scientific knowledge, medicalisation as an implicit or explicit control mechanism, inevitably incorporates value judgements by members of the profession, or which are latent in medical technologies.   “…medical social control is the accept­ance of medical perspective as the dominant definition of certain phenomena…. Medical social control of deviant behaviour is usually a variant of medical intervention that seeks to eliminate, modify, isolate or regulate behaviour, socially defined as deviant, with medical means and in the name of health.”

Older institutions for the control of deviance are religion and the law. Religious and legal authorities define moral rules attempting to reduce, eliminate or modify deviant behaviours in the name of moral correction. The main differences between these forms of control are in the conceptualisation of causes of and response to deviance. Under religious and legal institutions the deviant is assumed morally responsible. He is bad sinful or criminal, needing punishment. Under medical-scientific institutions which have been replacing and incorporating the other two, the person is not responsible and needs treatment. This change has been accomplished gradually over the past two centuries and consolidated in recent years. How this process occurred and its relationship to the production – and reproduction of scandals in chronic hospitals will be discussed below.

Medical treatment seems a more humane response to deviance than punishment, but our understanding of both punishment and  moral responsibility is ambiguous.   From the point of view of the ‘patient’ especially if his psychiatric treatment is involuntary, loss of liberty and the mode and effects of treatment may be as harsh and more permanent than imprisonment. Whatever the medical treatment, attributions of good and bad moral character depends on the degree to which the patient cooperates with medical advice and orders. In all hospitals, but especially the chronic sector, the good patient not only is cooperative, but also obedient, orderly, docile, and desirably helpful in performing useful tasks for staff.

There are three aspects to medical control of deviance,  namely technology, collaboration and ideology.   In the process of medicalising madness, collaboration was prior. The develop­ment and acceptance of medical ideology, reinforcing collaboration, was fought and won in the 19th century. Both preceded technological medicine. Psycho-surgery was first used in the 1930s. The psychotropic pharmaceutical ‘revolution’ dating from the 1950s is a technology embedded in capitalist economic growth. In collaborating with other agents of social control, doctors especially if employed within a total institution are more likely to be involved and identify with administrative concerns than with individualised consultation and treatment.

Three Stages in the Medicalisation of Deviance

There have been three stages in the medicalisation of dev­iance which parallel psychiatry’s development and incorporation into general medicine. The first stage, the emergence of mad-doctors in the 18th and 19th centuries and assumption of state responsib­ility for providing asylums will be discussed below. Asylum doctors or medical superintendents were isolated geographically and professionally from general medicine. What became classified as psychoses (ex-madness or lunacy) was assigned to psychiatrists’ jurisdiction. The second stage, the incorporation of Freudian ideas into general medicine at the end of the 19th century includes the ‘medicalisation of the mind’.   Taking place gradually from the 1920s with the discovery of neuroses, it overlaps the third stage, the development and widespread use of psychotropic drugs.

A ‘mental instability’ of lesser severity than insanity seemed to emerge   especially amongst women of higher social classes.   First diagnosed by Beard in 1880, it was labelled nerves or neurasthenia. Psychiatrists of the time, considered it with epilepsy and hysteria to be a precursor of insanity. As a condition characterised by nerve fatigue, it became the province of general medicine and neurology outside the asylum. Distribution of insanity to psychiatrists and neurasthenia to neurologists was disturbed in the second decade of the century due to the diffusion of Freudian ideas. “The appearance of psychoneuroses in medical texts merely formalised an increasing concern of general medicine with the ….ordinary mind of everyone” and the problems of coping with daily life. Neurosis was more than neurasthenia being caused by various kinds of stress to which all are exposed over the life cycle. “A general medicine which since the beginning of the 19th century had offered surveillance and examination to the body now extended its ‘gaze’ to the mind of everyone.” No aspect of humanity was a ‘taboo’ area for the medical profession. The most desirable form of treatment for neurosis was psychotherapy, restricted exclusively to medical practitioners. When health becomes a paramount value in society, but diagnosis and treatment are restricted to a specific occupational group, the opportunity to exercise and increase their power, influence and control to decide what should be done to achieve positive  health is reinforced.

The rediscovery of psychosomatic illness reversed ideas based on Cartesian dualism, legitimated the belief that there is no difference between mental and physical illness, and changed the asylum from a place for the confinement of the insane into the mental hospital for the treatment of patients. Various consequences must be noted. First, more cases were treated as out-patients, a policy incorporated in the 1930 Mental Treatment Act. The regime on some wards changed as patients with favourable prognosis had a range of treatments, somatotherapy, psychotherapy and the renaissance during and after the war of a kind of ‘moral treatment’– milieu therapy or the sociotherapy of the therapeutic community. The back wards experienced little change, remaining places of custody and control with an excessive use of restraints, mechanical, chemical, surgical and coercion. New practices in psychiatry largely passed by subnormality and psychogeriatric wards in which conditions for the production of scandals exist.

A second consequence, the development of the ‘panoptic vision’ of a total medicine, produced the mental hygienist. Practitioners claiming expertise in psychological medicine, aided by psychologists could survey and classify whole populations into suitable educational and employment pathways to reduce stress, improve personality and daily functioning, and identify latent mental disorder.   The most important group to monitor are children, to detect anti-social behaviour or symptoms of emotional disturbance. Such children are perceived to be ‘at risk’ of becoming maladapted adults or even suffering  from severe mental disorder.  Without medical intervention their fate seems inevitable, as neurasthenia caused by the habit of masturbation was believed to be the precursor of insanity.

A panoptic vision encompassing individuals or whole communities is conducive to the third stage in the medicalisation of deviance, the widespread prescribing of psychotropic drugs. These are a major and profitable technology for the control and treatment of a range of undesired conditions such as anxiety, depression, obesity and newly discovered diseases like hyperkinesis.   Drugs “are easily administered, under professional medical control, quite potent in their effects….and are generally less expensive than other treatments and controls (eg. Hospitalisation, altering environments, long-term psychotherapy)”  They also have enabled psychiatrists to “engage in the prescription and administration of the classic symbolic accoutrement of the modern medical man” rather than act “as glorified administrators  of custodial warehouses.”

Medicalisation of deviance locates pathology in the individ­ual psyche. Pathology is believed to be transmitted intergenerationally genetically or culturally. Medical ideology depoliticises issues as poverty, poor housing, ethnic discrimination, un­employment which can be stressful. It operates to support dominant social, economic and political interests.   This is not a new phenomenon. The American pre-civil war condition, drapetomania, afflicted slaves whose symptom was the attempt to escape.   If caught, their treatment was mechanical restraint or foot surgery. A more recent example is the actual or proposed use of psycho surgery to control violent, destructive anti-social behaviour.

After urban riots and assassinations in the 1960s, some neuro-surgeons, reputation and career enhanced by research and publications, suggested rioters, looters and others had brain dysfunction. The lesson gained from social unrest was not improving the social situation of the deprived, nor increasing forces of law and order, but “We need intensive research and clinical studies of the individuals committing the violence…. to pinpoint, diagnose and treat….people with low violence thresholds before they contribute to further tragedies.”

All treatments whether or not based on a medical model of causation can be criticised when they are employed within a setting dominated by medical ideology.   The eclectic and reasonable approach of Clare, whilst eschewing dogma, supports the proposition that psychiatry is a medical specialism. Psychosurgery is irreversible and may create paralysed ‘vegetables’, epileptic seizures and confusion. This is not seen as a scandal although it could result in litigation for medical malpractice.   Excessive use of drugs has been criticised because of iatrogenic effects   and their ambiguous, purpose for control, as chemical strait-jacket, or treatment. Their effectiveness is problematic. Despite claims as a therapeutic revolution, evidence is increasing drugs can prolong hospitalisation.

Psychotherapy, group therapy and behaviour modification all attempt to resocialise in the direction of the patient’s adaptation and conformity to extant norms and values. Both medical and psychoanalytic models of mental illness depoliticise public issues by reducing them to personal plights. The medical model, whether used to explain crime or mental disorder, reduces individual autonomy and responsibility for actions.   For the chron­ically impaired confined in hospital, the medical model has de­personalising and dehumanising effects as the patient learns dependency, further undermining any sense of self-determination. The staffs main task is control and maintenance of order.

The Emergence of Mad-doctors and the State’s Assumption of Responsibility, 18th and 19th Centuries

Psychiatric historians explain the changed conceptualisation of insanity from religious and demonological beliefs to the medical model as evidence of enlightened scientific and humane progress.   Contemporary documents show that what became inc­reasingly perceived as scandalous malpractices and barbaric cruelties were perpetrated and perpetuated by doctors and staff under their control. Scull discusses the social processes enabling mad-doctors to become professionally organised as psychiatrists with a “monopolistic power to define and treat lunatics.

If a group is to become recognised as suitable experts, the amorphous mass of the ‘dangerous classes’ must first be differentiated. This occurred gradually as the formal state apparatus of control, developing concurrently with industrial capitalism, provided institutions for the incarceration of deviants.

The ‘great confinement’ in many European countries during the 17th century had roots in social, political and economic changes with the shift to wage labour, and in earlier values and images attached to lepers. Vagabonds, criminals, and ‘deranged minds’ became the new deviants to be controlled with military invalids and the poor of all ages, able-bodied or sick. With the establishment of the Hospital General in Paris in 1656, 1% of the population were confined.

In England an Act of 1575 prescribed the building of houses of correction for “the punishment of vagabonds and the relief of the poor.” Places of confinement were provided by local magistrates and private individuals without the need for licensing. ‘ Workhouses and jails were frequently “leased to entrepreneurs who hoped to exploit the deviants’ labour power.” Throughout Europe there was “a new sensibility to poverty and the ….duties of assistance, new forms of reaction to economic problems of unemployment…. a new ethic of work….moral obligation was joined to civil law, within…. authoritarian forms of constraint. ”

Defoe’s condemnation, in 1706, of detaining unwanted wives or rich relatives led to an increased interest in insanity. A series of letters and articles alleging abuses appeared. By 1754 some M.P.s asked the College of Physicians to inspect mad­houses, but they declined. Further articles resulted in the appointment of a Select Committee of the House of Commons and investigations of two London establishments, revealing confinement of sane persons for profit. The provisional act, 1774, subsequently made permanent, allowed licensing and inspection of madhouses in London by five Commissioners appointed by the College, and by magistrates elsewhere.   It also required medical certification before confinement of non-pauper lunatics, but did not apply to paupers. For the past two centuries there seems to have been very little concern about the lifelong detention of poor inmates.

Other class difference in the modes of control were always apparent. Whilst the rich were often placed individually in the care of doctor or clergyman, the poor were confined in madhouses, workhouses, jails or charitable hospitals.   Demand was increased by the 1744 Vagrancy Act, which for the first time distinguished lunatics from other paupers, enabled J.P.s to securely detain them. Most remained in the community sup­ported by family or outdoor relief. Madhouse proprietors, grad­ually included an increasing number of physicians, surgeons and apothecaries who shared a profitable activity. Often several generations of one family owned and managed the madhouse. Haskins, apothecary at Bethlem giving evidence to the 1815 Select Committee said he did not chain lunatics in his private  madhouse, chains were only for paupers.   “Personal restraint should seldom be resorted to, particularly with the more respectable class, their feelings are more acute than those of humbler grade.”   During the 19th century the rise in the rate of confin­ing pauper lunatics nearly doubled whilst that for private cases hardly changed.   This ignores the fact that many pauper lunatics remained in workhouses which were cheaper than asylums.

One of the first perceiving the care of the insane as cruel was Dr. Battie of St.Luke’s, who in 1758 considered, “such unhappy objects ought..(not) abandoned, much less shut up in loathsome prisons as criminals or nuisances to society.”   His contemporaries went to view chained lunatics at Bethlem for entertainment, or learned from Dr. Brown that mania being sthenic apyrexia (non-inflammatory excitement) was cured by exhaustion through heavy labour, poor diet, and controlled by fear increased by whipping.   Public awareness was sensitised to insanity by the recurrent illness of George III, the assassination of the Prime Minister by an alleged lunatic, the revelations of unexpected deaths and other brutalities including the case of Norris.   If the King was subjected to chaining, beatings, starvings, purgings, vomits and bleedings, one cannot attribute such practices to the cupidity of entrepreneurs. The treatment of the physically sick involved similar practices, but not beatings and chaining.

That madmen were beasts requiring restraint, force and fear was taken for granted, “..the madman was not a sick man…unchained animality could be mastered only by discipline and brutalizing” not appeals to reason.   Such beliefs provided a useful smokescreen for the needs to contain costs, resulting in overcrowding, few attendants and the necessity for mechanical restraints and coercion. Many buildings were unsuitable, insanitary, the stench overpowering.   Subsequent ideologies, following the brief period of therapeutic optimism   derive from Malthus, Riccardo, Adam Smith, Bentham, Darwin and Galton. Social Darwinianism, made explicit by Spencer, justified opposition to indiscriminate relief, producing the workhouse test of less eligibility. The least fit and capable of social and economic survival in a competitive society, deserve the lowest priority in the allocation of collective resources.   The Eugenic movement, based on belief in genetic predeterminism, led to pessimistic self-fulfilling prophecies. Maudsley writing in 1873-4 noted some are born so defective “all the education and training in the world will not raise them above the level of brutes.” For others, no care “will prevent them being vicious, criminal or becoming insane.”  Idiocy was attributed to parental transgress­ions like drunkenness, reinforcing inherited nervous instability. Children of low intelligence were born to women who violated natural law by being educated.   That innate degeneracy was manifest in the habit of masturbation was problematic for upper class Victorians, favouring deferred marriage. What still escapes the understanding of hospital staff is lack of any activities may lead to self-stimulation and mutilation.

Early initiatives for reform came from lay persons, magistrates, Quaker businessmen, philanthropists rather than doctors, who lacked any clear idea of what tax-supported asylums should be like. Following the 1808 Act, some counties deferring to med­ical opinion, built asylums modelled on existing madhouses, soon to be condemned for their barbaric and cruel features.   Malpractices often discrediting the medical profession   were ex­posed in a series of investigations and Select Committees. Attempts at radical reform were consistently blocked by the House of Lords seeing no need for a centralised system of state asylums, more rigorous inspections which could curb entrepreneurial profits and local magistrates’ autonomy.

Pressures to establish a full-time national inspectorate continued, joined by those asylum doctors espousing moral treatment who sought reforms.   Lacking public asylums, many pauper lunatics were confined in jails, workhouses and traditional mad­houses “under the care of persons ….ignorant of the(ir) proper treatment…”   Therapeutic optimism   led to the belief that humane care on a mass scale in specialised institutions was possible and could effect cure. The1845 Lunatics Acts finally established a permanent inspection system under a national Lunacy Commission, and made the erection of county and borough asylums compulsory. Authorities could “erect separate, less costly buildings for chronic lunatics” so that cure of, mainly middle class, patients with good prognosis would be unimpeded.   Thus from the start the distinction between good and bad wards was institutionalised.

The prerequisite for perceiving the treatment of lunatics as morally scandalous was new beliefs regarding the nature of madness. The lunatic lacked self-control and normality, but was nevertheless human, not beast.   From being unknown in 1800,  by 1850 moral treatment was in every textbook and asylum. Paternalistic humanitarians arguing for moral treatment were part of an Evangelical movement preaching self-help and self-discipline, in the context of industrial capitalism demonstrating man could be master of his own salvation.   Moral treatment provided means by which “the power of the patient to control the disorder is strengthened and assisted.”   As with the rearing of children, lunatics needed rewards and punishments. Order from within, not by externally imposed sanctions, was applicable to industrial workers and lunatics alike. Activities promoting normality were divided along class lines: craft, domestic and agricultural work for labourers; books, music, games, needlework for leisured classes who could keep their personal servants.

If moral treatment provided an alternative to traditional medical practice, how did the profession, so thoroughly discredited by evidence to Select Committees   regain the initiative and acquire monopoly control of care of the mentally disordered, retained to this day? Based on commonsense, kindness, lacking scientific potential to become specialist knowledge, moral treatment and its unorganised proponents did not try to compete.

There were no alternative occupational groups to establish a claim; magistrates might visit but did not want daily involvement. Educationalists were scarce, disinterested, unorganised,still a semi-profession today; social workers nonexistent, social science in its infancy.   “Promoters of moral treatment…employ(ed) a vocabulary laden with terms borrowed from medicine. Given the critical role of language in….the social construction of reality…. to imply something is a medical problem and…deny that doctors are….most competent to deal with it, seems perverse.

Doctors not converted to moral treatment began to create, disseminate and incorporate into the training curriculum a body of spurious ‘scientific1 knowledge which the public could not comprehend. Resentment of supervision and inspection of asylums by magistrates was made clear to Parliament. The editor of the Lancet, 1842, declared insanity a “grevious disease”; inspection by lawyers unaccompanied by doctors “an insult…”   Mind and body might be distinct, but brain through which mind operates was subject to disease, thus part of medical jurisdiction. Physical aspects of moral treatment like baths required medical supervision. A combined moral and medical approach was the most efficacious.

The 1828 Act required medical attendance at all asylums weekly, with a medical superintendent if there were more than 100 patients. The 1845 Acts provided for equal legal and medical representation on the Lunacy Commission; most magistrates charg­ed with providing new asylums accepted management should be vested in a resident physician. Under the Acts “..doctors… controlled the …legitimate institutions for the treatment of the insane, and….influence(d) (how) mental disorder was to be construed by lay opinion.” ‘ Further stages in the metamorphosis of mad-doctor or alienist to professional psychiatrist included establishment of an occupational association and publication of a journal emphasising somatic treatment. But as salaried state employees in “an isolated specialty with only superficial ties with the rest of” medicine their professional status was precarious.

There was no need for medical superintendents to demonstrate the effectiveness of their skills to attract patients – the state system of social control provided an abundance of pauper lunatics, many elderly, most incurable. The public relieved of deviants were indifferent.   Job security was enhanced by willingness to combine administration with medical supervision. Two positions filled at the price of one attracted cost-conscious magistrates.

As the asylum population grew, producing economies of scale, superintendents retreated to administrative duties, leaving the ‘dirty work’ of daily care increasingly to untrained attendants recruited from the same social strata as inmates.

Given the “choice between hypothetical cures” in a small asylum and “concrete savings” in custodial warehouses   magistrates forgot about labour-intensive moral treatment and accommodated ever more patients in the same space. In any case moral treatment depending on the personal qualities of the care-giver required staff of a calibre and number unlikely to be forthcoming. Asylums being an unproductive burden on the rates, authorities were not generous employers, relying on the more able inmates to contribute to their upkeep. The pay of attendants was similar to agricultural labourers and domestic servants; their long hours often involved sleeping near the ward.

The scandal of chaining was replaced by increased use of seclusion, strait-jacket and coercion. The Metropolitan Commissioners noted in 1844, if Visitors “require an absence of restraint, the public must be prepared to pay an additional sum for the care….of patients, otherwise they must either suffer long…. solitary seclusion ….or the attendant and other patients will be exposed to constant peril.”   The brief period of therapeutic optimism evaporated, replaced by ideas of genetic predetermination, “…medical control of asylums and …propaganda about treatment rather than punishment served to legitimate further the custodial warehousing of….the disreputable poor.”

To manage huge numbers required bureaucratic routines. Rules were enforced by a system of rewards and punishments including transfer to better or worse wards. The outcome of reform was the creation of vast receptacles in which “..a patient may be said to lose his individuality and become a member of a machine. . ,mov(ing) with precise regularity and inevitable routine ….drilled into order and guided by rules, but not an apparatus calculated to restore…. their independent self-governing existence. ”

All the problems and most of the scandals of chronic hospitals rediscovered by the literature of the 1950s and after were already extant by 1850. It is to this literature, concerned with the interrelations between social organisations, treatment culture and patient care, we now turn.