The Bugs in Our System

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One of the most important pieces of literature the 20th Century gave birth to is, arguably, Franz Kafkas’ metamorphosis.  Now I am not a literary buff and neither do I read German; so I am unable to give you the classical reasons as to why this book is the work of art that the academics say it is.  What I can supply, however, is my own experience of the story which has unintentionally found an interwoven link with my profession of nursing.

For those who have not read it or need a reminder,  Gregor Samsa is a young travelling salesman who has been the sole breadwinner for his family since his father went bankrupt some years before. Devoted to his family but disillusioned with the way his life has turned out, we meet Gregor as he wakes one morning with the realisation that he has turned into a bug, vermin, creature (to be honest, Kafka leaves a lot to our imagination).  Gregor is obviously alarmed at this predicament but is completely and utterly consumed with the fact that he has woken late and will miss his transport to work.  It is from this point that the remaining events in the story surrounding Gregor’s transformation occur in an air of normality: his personal struggle with transformation, his family’s reaction, the mutual concern and horror, the loss of compassion and love and ultimate daily physical and emotional abuse.

I have to confess to finishing Metamorphosis with a small amount of bafflement as to what the fuss was about. It doesn’t slap you round the face that it is a masterpiece. It is very simply written, a tale apparently told for the sake of telling a tale.  Gregor, far from being a source of terror for the reader, is a rather pathetic thing that spends most of his time hiding under a sheet and considering his families feelings even when they are throwing apples at him or neglecting him to the confines of his dusty, increasingly cluttered room.  The characters speak for themselves.  Their actions carry the story. There are no obvious heroes or villains and no one that you immensely like or dislike. There is no one in the book who you feel is any different from their neighbour or my neighbour or yours.  The abuse, throughout the book is normalised and rationalised by the Samsas so much so that one initially sails through the story without so much of tickle of discomfort. It is this normalisation of abuse by the victim, the perpetrators and the system however, which gradually gives birth to a niggling, menacing sense of unease as you try to leave the story behind.

The existence of the Samsa family is placed against the back drop of financial necessity and need.  People go to work, people are an asset or a hindrance. There are no dreams that will ever be fulfilled because these play second fiddle to the need to bring home the money.  Thus, in the story, we see that a persons’ worth is based on what they can give to society. Arguably, if Gregors’ father did not have his son, his worth to society as a financial asset would be nothing.  It is this tension that drives the book. The father is part of society purely through the money that his son earns. So we see that once, Gregor loses his wage earning ability, his position in life becomes less and less notable to the point where he is no longer physically human and no longer behaves as a human. He is no longer programmed with the same motivations. Gregor ultimately is kept in a room with all the unwanted furniture and rubbish of the house.  His corpse is finally disposed of with the rubbish, the flat sold, and the family find themselves in a better financial position. The utter tragedy of the story is that Gregor has immense visions and dreams for his family, especially his sister whose dreams of a musical career he wishes to fund, but his selflessness is lost in his inability to communicate and contribute to society.

The parallels are endless in the society we meander around in with our own take on meaning and position in life.  We like to think that we do not have any Gregor Samsas in our midst.  We are good at highlighting and raising the profile of certain groups of the disadvantaged. We pour money into areas which upset us or inspire us the most.  Children’s hospices, Cancer Research, equal opportunities, anti-racism, feminism, LBG issues, disabilities are all issues that are rightly acknowledged but, in this information age, give us the sense that no stone has been left unturned.  Every angle is covered.  There is no Gregor in the cupboard.  But, I am sorry to say, there are many Gregors and the chances are good that many of us will end up the same way.

The health service is currently operating under the shadow of what happened in Mid Staffs Foundation Trust.  The Care Quality Commission has highlighted recurrent lapses on a national level of even basic care.  Many patient groups have been affected but time and again, the group most affected is the elderly.  The area of care which consistently receives the least resources in staff and finances always seems to be geriatric medicine and care.
How many people working in healthcare have stories where attitudes and efforts to care and nurse for a patient with end stage dementia have been compromised due to lack of time, staff and top cover support.  How many times have they seen compassion become threadbare thin in a department jam packed full of patients with the most complex needs and yet accepted as not ideal but the norm? This against a back drop of an increasingly privatised health services which is being fed to the wolf pack of business and the open market. Of course this compassion fatigue isn’t just experienced in the health profession.

I recall numerous times when an elderly patient with dementia has died alone, not because they didn’t have family, but because family no longer possessed the compassion to make the journey to be with them. I recall odd occasions when an elderly spouse has been informed their other half is going to die and they have prioritisde shopping and daily routine before making the bus journey to the hospital. One elderly gentleman made the motivation behind this clear one day.

“My wife died ten years ago when the dementia got bad and she could no longer be herself or recognise me. She doesn’t know I’m here and I did my mourning ten years ago.”

We might feign horror at such an attitude, but I can understand that for someone like him, with minimal resources for coping, with little support from family or state and health service, this position was one of survival rather than choice. Loss of compassion is hardly ever born from villainy and almost always born from lack of emotional and physical resource and support.

And yet while we ponder the sadness of that gentleman’s loss and his wife’s desolation, we are as guilty of this lack of compassion as anyone else.  Surely this gentleman’s attitude was born from our culture nurturing this attitude that people can live without being human. That once someone no longer contributes to our society, certain rights can be dismissed through necessity because of lack of resources.  With how many other groups of people would we deem acceptable the relinquishment of their beloved homes to the state followed often by limited choice of accommodation according to how much their property fetches or whether they have given anything to the state.  With how many other patient groups would we find it acceptable to shift a dying person off to “any available bed” on any ward rather than care for them in the home they are comfortable in with the people they recognise and trust?

What kind of country are we that we have built into our culture an acceptance of this? The abuse is not just based on the callous actions of a minority. It is ingrained in the very structure of how we care for the elderly and how we encourage the perceptions the elderly build up about themselves. 

I have heard, countless times, a person with dementia being described by lay people as having reverted to being a toddler.  And yet how different the reaction toward a confused toddler to that of a confused elderly man or woman. This is a grossly inappropriate comparison but this is the essence of the problem.  This is why Gregor gets shut up in his room.  The loss of potential in a living human being switches off the connection between two humans as easily as a light switch turns of a lamp.  We have been trained and nurtured as a nation to turn on to what another being can offer.  When that potential withers, we sadly and sheepishly put in place measures to hide those non contributors away where we cannot see them. Worse still, our culture trains these people to hide themselves away. It convinces them that they will become a burden. The literature reviews I have conducted into end of life care for the elderly, suggest that a large amount of people fear or wish to avoid putting a burden on their loved ones and that they are prepared to sacrifice most things to do so.

Of course, in my practise I see a great deal of relatives who refuse to be conditioned by the above. They refuse to let their mother, father, sister or brother become another Gregor Samsa.  These are people who sacrifice everything and seem to possess an endless supply of compassion and love which refuses to be rationed or suppressed.  They are not the exception, but often their voice is often not heard once their loved one is enveloped in the system of care. Their advocacy takes a lower priority over financial funding and resources.  It is brings me back my faith in humanity when I see a daughter fight and weep for their mother’s rights, but it makes me desperately sad to see it.  I’m sure it would make most people desperately sad to see it; but how many times will that daughter meet a professional who will say, “I understand but there is nothing I can do.”

We can blame culture and society and the health system and lack of resources. We can point fingers when another report comes out. We can raise an eyebrow or two whilst we read the papers over a morning coffee. Of course what we neglect to remember whilst we are busy analysing causes and effects and  “factors” is that we are the very culture and society that we blame. The tragedy of Metamorphosis is that everyone in the story, including Gregor, forgets that he is human right up to the end of the story. The only one aware of this is the reader and the reader is helpless to assist. The parallel between Gregor and how many elderly people are treated is too close.  Unless we personally radically shift our cognition of what it is to be human and what is ethically and morally horrific, we will continue to ignore the tragedy and horror that befalls a large and increasing proportion of our population.

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