How fiction makes us better people: an analytic account of how fiction succeeds in being morally developmental

M.A. University of the Witwatersrand, Faculty of Humanities, 2012That works of fiction are morally developmental is a commonly accepted claim. However, works of fiction are epistemically dubitable. As such, any account of the morally developmental nature of fiction ought to be one on which moral development is conceived of as occurring indirectly. It is the claim of this dissertation that extant accounts of the morally developmental nature of fiction fail to do so. The positive thesis of this dissertation is that moral development can be brought about through an experience of irony. This dissertation employs Jonathan Lear’s account of irony on which an experience of irony can be occasioned by bringing the subject to recognise the disparity between a concept, understood as a social pretense, and the same concept understood as a human ideal. Subjective concepts, including the moral virtues, are such that exemplifying the ideal consists in being in a constant state of coming to exemplify the ideal. The virtue of mercy is explicated in full. It is shown that mercy involves firstly, paying attention to the particulars of a wrongdoing, secondly, the dissolution of negative affective responses to wrongdoing, and thirdly, a sense of moral humility. Fiction, by virtue of its narrative and mimetic nature, is capable of inducing these three states. Furthermore, by occasioning an experience of irony, fiction succeeds in drawing the reader into a state in which she is constantly striving to exemplify mercy as a human ideal. In doing so, fiction succeeds in making the reader merciful. It does so, without directly asserting any positive claims. The account is thus not susceptible to the epistemic dubitibility objection

Health systems and social values: the case of the South African health system

Health systems are complex social systems – driven by people and the relationships between them, characterised by feedback loops and path-dependency, and open to contextual influences. This entails that social values are an important determinant of health system change. In addition, health systems play a vital social role as generators of social value. However, the influence of social values on health systems is an under-explored field of study, and the evidence-based on the topic is weakened by conceptual confusion, a lack of theoretical models to support rigorous research, a dearth of empirical evidence, and methodological challenges attendant to the study of intangible factors such as values. In this theory-building study I explore the relationship between health systems and social values. Firstly, I use evidence mapping, interpretive synthesis and scoping review approaches to identify gaps in the existing evidence-base, develop an initial explanatory theory for the social value of health systems, and integrate insights from social sciences to establish a working definition of values, explore the social dynamics of values, and develop an account of the relationship between social systems – including health systems – and social values. Secondly, I conduct a case study of social values in the South African National Health Insurance policy process in its social and political context to gather empirical evidence on the role of social values in health system reform processes, and the mechanisms by which health systems shape social values. Lastly, I integrate the findings from the first two phases to develop a conceptual framework of the relationship between health systems and social values and offer methodological and conceptual insights intended to support further research on the topic. This study finds that social values, often borne out of social and political history, are cemented in health systems through daily practices and procedures. In this way, health systems serve to shape social values – by changing the way people think about what is just with respect to healthcare, their health rights and entitlements, and the appropriate role of the state in providing healthcare and regulating the behaviour of other health system actors

Countertransference in rape counselling

The study examined rape counselling, with particular emphasis on countertransference reactions experienced by the counsellors of rape survivors. Four subjects participated in semi-focused, open-ended interviews, which were taped and transcribed verbatim. The phenomenon of countertransference was discussed, and countertransference reactions identified and examined. The management of empathic strain, in order to sustain empathic inquiry and therapeutic efficacy, was discussed. The main results of the study included the identification of common victim themes, and the feelings evoked in the counsellor in the therapeutic relationship. These included feelings of anger, hopelessness, helplessness and sadness, particularly in the counselling of children, who may be HIV positive as a result of the attack, and victims of chronic abuse. Challenges of rape counselling included shortcomings in the system, and rape myths which trivialize the crime and blame the victim. The need for education and enlightenment of both the public and magistrates on the deleterious effects of rape was emphasized by all subjects

What is Covid-19 teaching us about community health systems? A reflection from a rapid community-led mutual aid response in cape town, South Africa

The coronavirus disease 2019 (COVID-19) pandemic has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of selforganising, neighbourhood-level community action networks (CANs) has contributed significantly to the communitybased response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential

Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast

Background: Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal. Methods: Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa’s power cube and Long’s actor interface analysis. Results: We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs’ and SCHMTs’ capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents. Conclusion: Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required

Health system responsiveness: A systematic evidence mapping review of the global literature

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems’ functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness

What is Covid-19 teaching us about community health systems? A reflection from a rapid community-led mutual aid response in Cape Town, South Africa

The coronavirus disease 2019 (COVID-19) pandemic has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of selforganising, neighbourhood-level community action networks (CANs) has contributed significantly to the communitybased response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential