Borderland practices*

Borders and boundaries seem to have taken on extra importance over the last few months, especially since COVID appears to be entirely indifferent to national borders, and its existence relies on its ability to move freely between us.

We’ve spent the summer in New Zealand thanking our lucky stars that we live a long way away in the bottom corner of the South Pacific, and the ability to close our borders has meant life has relatively normal. People can hug and move freely, gather in groups, and care for loved ones.

Because of our accident of geography, we’ve been incredibly lucky to have so far dodged the COVID bullet. But even here there are people who object to the government over-reach. And at the heart of all of these conversations are questions of borders and boundaries.

Since mid-December I’ve been on my own self-imposed writing retreat, trying to finish off the follow-up to The End of Physiotherapy. And this new book is very much about boundaries and borders, especially those between physiotherapy and society.

Long-held professional boundaries around physiotherapists are disappearing at a remarkable rate at the moment. Forced by circumstance, clinicians and educators are working and teaching in ways that would have been unimaginable (and, in some cases, impossible) only a few years ago. And they are doing jobs that were once the sacred territories of other professions. But what is remarkable is that much of this is happening without anything like the kinds of resistance offered in the past.

Giorgio Agamben has called the present moment a ‘state of exception’ (Agamben, 2015); a time when the normal social rules and conventions are forgotten, and all manner of new ways of thinking and acting become possible. States of exception can be terrible things, especially when despots use their power to commit genocide in the name of national interest. But they can also be a circuit breaker, forcing creativity on people who might otherwise feel no pressure to change.

So while so much of the current discourse is around the availability of vaccines, lockdowns, and altered scopes of practice, a lot of it is really about borders and boundaries: between a virus and the body; between the person and the state; between one professional and another.

People are already thinking about what healthcare will look like in a world where the worst of COVID has passed, and so much of this conversation is about borders. But, of course, it is also about power: power to control a market; power to control one’s own professional destiny; power to keep competitors out and good practitioners in.

The question, however, is not so much about what represents the ‘right’ redesigned border for the health professions, but who decides. Should it be the government, insurance companies, academics, practitioners, researchers, or clients that decide what physiotherapy is and isn’t? Or should it be a coalition of all of these? If so, how is such a coalition formed? And who decides what represents ‘good’ physiotherapy in the future?

If one thing is certain, it is that physiotherapists will not be able to rely on the same boundary protections they once enjoyed, because healthcare has already become far too complex, uncertain, and diverse for practice models that really originated in the first half of the 20th century.

This means that the way we define what physiotherapy is and isn’t is going to change. It certainly looks like it may become more diffuse and ambiguous, and far less concrete than it has been in the past.

How we build a border around that, and ‘sell’ that image to our colleagues and consumers (or even, whether a new border to replace the old one is the right way to think about future healthcare), may well define what we teach, think about, and practice for the next 50 years. So borders and boundaries are definitely something that feels worth thinking about right now.

*The title for this post comes from a fabulous book by a Kiwi sociologist Kevin Dew, detailing a classic border dispute between physiotherapy, medicine and chiropractic in the 1990s in New Zealand. The book is well worth a read if you can find a copy.

References

Agamben, G. (2015). Homo sacer. Vancouver: BC Crane. 

Dew, K. (2003). Borderland Practices: Regulating Alternative Therapies in New Zealand. University of Otago Press.