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Tuesday, November 21, 2006

"How the Poor Die"

I stumbled across this essay by George Orwell. It was written in 1946 and it's about his experiences as a non-paying patient in a ward of a hospital in France in 1929. At this time, "If you are seriously ill and if you are too poor to be treated in your own home, then you must go into [a] hospital." The essay explains why "The dread of hospitals probably still survives among the very poor, and in all of us it has only recently disappeared." There isn't much in the way of explicit economics, but for those who are interested it's a fairly descriptive look at health care for the poor in this particular hospital at this time in history.

There are economic implications however. For example, making the poor paying customers through national health insurance improves the quality of care:

Moreover, the national health insurance has partly done away with the idea that a working-class patient is a pauper who deserves little consideration. Well into this century it was usual for ‘free’ patients at the big hospitals to have their teeth extracted with no anaesthetic. They didn't pay, so why should they have an anaesthetic — that was the attitude. That too has changed.

Here's the essay:

How the Poor Die, by George Orwell, 1946: In the year 1929 I spent several weeks in the Hôpital X, in the fifteenth arrondissement of Paris. The clerks put me through the usual third-degree at the reception desk, and indeed I was kept answering questions for some twenty minutes before they would let me in. If you have ever had to fill up forms in a Latin country you will know the kind of questions I mean. For some days past I had been unequal to translating Reaumur into Fahrenheit, but I know that my temperature was round about 103, and by the end of the interview I had some difficulty in standing on my feet. ...

After the questioning came the bath — a compulsory routine for all newcomers, apparently, just as in prison or the workhouse. My clothes were taken away from me, and after I had sat shivering for some minutes in five inches of warm water I was given a linen nightshirt and a short blue flannel dressing-gown — no slippers, they had none big enough for me, they said — and led out into the open air. This was a night in February and I was suffering from pneumonia. The ward we were going to was 200 yards away... Someone stumbled in front of me with a lantern. The gravel path was frosty underfoot, and the wind whipped the nightshirt round my bare calves. When we got into the ward I was aware of a strange feeling of familiarity whose origin I did not succeed in pinning down till later in the night. It was a long, rather low, ill-lit room, full of murmuring voices and with three rows of beds surprisingly close together. There was a foul smell, faecal and yet sweetish. As I lay down I saw on a bed nearly opposite me a small, round-shouldered, sandy-haired man sitting half naked while a doctor and a student performed some strange operation on him. First the doctor produced from his black bag a dozen small glasses like wine glasses, then the student burned a match inside each glass to exhaust the air, then the glass was popped on to the man's back or chest and the vacuum drew up a huge yellow blister. Only after some moments did I realize what they were doing to him. It was something called cupping, a treatment which you can read about in old medical text-books but which till then I had vaguely thought of as one of those things they do to horses.

The cold air outside had probably lowered my temperature, and I watched this barbarous remedy with detachment and even a certain amount of amusement. The next moment, however, the doctor and the student came across to my bed, hoisted me upright and without a word began applying the same set of glasses, which had not been sterilized in any way. A few feeble protests that I uttered got no more response than if I had been an animal. I was very much impressed by the impersonal way in which the two men started on me. I had never been in the public ward of a hospital before, and it was my first experience of doctors who handle you without speaking to you or, in a human sense, taking any notice of you. They only put on six glasses in my case, but after doing so they scarified the blisters and applied the glasses again. Each glass now drew about a dessert-spoonful of dark-coloured blood. As I lay down again, humiliated, disgusted and frightened by the thing that had been done to me, I reflected that now at least they would leave me alone. But no, not a bit of it. There was another treatment. coming, the mustard poultice, seemingly a matter of routine like the hot bath. Two slatternly nurses had already got the poultice ready, and they lashed it round my chest as tight as a strait-jacket while some men who were wandering about the ward in shirt and trousers began to collect round my bed with half-sympathetic grins. I learned later that watching a patient have a mustard poultice was a favourite pastime in the ward. These things are normally applied for a quarter of an hour and certainly they are funny enough if you don't happen to be the person inside. For the first five minutes the pain is severe, but you believe you can bear it. During the second five minutes this belief evaporates, but the poultice is buckled at the back and you can't get it off. This is the period the onlookers enjoy most. During the last five minutes, I noted, a sort of numbness supervenes. After the poultice had been removed a waterproof pillow packed with ice was thrust beneath my head and I was left alone. I did not sleep, and to the best of my knowledge this was the only night of my life — I mean the only night spent in bed — in which I have not slept at all, not even a minute.

During my first hour in the Hôpital X I had had a whole series of different and contradictory treatments, but this was misleading, for in general you got very little treatment at all, either good or bad, unless you were ill in some interesting and instructive way. At five in the morning the nurses came round, woke the patients and took their temperatures, but did not wash them. If you were well enough you washed yourself, otherwise you depended on the kindness of some walking patient. It was generally patients, too, who carried the bedbottles and die grim bedpan, nicknamed la casserole. At eight breakfast arrived, called army-fashion la soupe. It was soup, too, a thin vegetable soup with slimy hunks of bread floating about in it. Later in the day the tall, solemn, black-bearded doctor made his rounds, with an interne and a troop of students following at his heels, but there were about sixty of us in the ward and it was evident that he had other wards to attend to as well. There were many beds past which he walked day after day, sometimes followed by imploring cries. On the other hand if you had some disease with which the students wanted to familiarize themselves you got plenty of attention of a kind. I myself, with an exceptionally fine specimen of a bronchial rattle, sometimes had as many as a dozen students queuing up to listen to my chest. It was a very queer feeling — queer, I mean, because of their intense interest in learning their job, together with a seeming lack of any perception that the patients were human beings. It is strange to relate, but sometimes as some young student stepped forward to take his turn at manipulating you he would be actually tremulous with excitement, like a boy who has at last got his hands on some expensive piece of machinery. And then ear after ear ... pressed against your back, relays of fingers solemnly but clumsily tapping, and not from any one of them did you get a word of conversation or a look direct in your face. As a non-paying patient, in the uniform nightshirt, you were primarily a specimen, a thing I did not resent but could never quite get used to.

After some days I grew well enough to sit up and study the surrounding patients. The stuffy room, with its narrow beds so close together that you could easily touch your neighbour's hand, had every sort of disease in it except, I suppose, acutely infectious cases. ...

About a dozen beds away from me was Numéro 57 — I think that was his number — a cirrhosis-of-the-liver case. Everyone in the ward knew him by sight because he was sometimes the subject of a medical lecture. On two afternoons a week the tall, grave doctor would lecture in the ward to a party of students, and on more than one occasion old Numéro 57 was wheeled in on a sort of trolley into the middle of the ward, where the doctor would roll back his nightshirt, dilate with his fingers a huge flabby protuberance on the man's belly — the diseased liver, I suppose — and explain solemnly that this was a disease attributable to alcoholism, commoner in the wine-drinking countries. As usual he neither spoke to his patient nor gave him a smile, a nod or any kind of recognition. While he talked, very grave and upright, he would hold the wasted body beneath his two hands, sometimes giving it a gentle roll to and fro, in just the attitude of a woman handling a rolling-pin. Not that Numéro 57 minded this kind of thing. Obviously he was an old hospital inmate, a regular exhibit at lectures, his liver long since marked down for a bottle in some pathological museum. Utterly uninterested in what was said about him, he would lie with his colourless eyes gazing at nothing, while the doctor showed him off like a piece of antique china. He was a man of about sixty, astonishingly shrunken. His face, pale as vellum, had shrunken away till it seemed no bigger than a doll's.

One morning my cobbler neighbour woke me up plucking at my pillow before the nurses arrived. ‘Numéro 57!’ — he flung his arms above his head. There was a light in the ward, enough to see by. I could see old Numéro 57 lying crumpled up on his side, his face sticking out over the side of the bed, and towards me. He had died some time during the night, nobody knew when. When the nurses came they received the news of his death indifferently and went about their work. After a long time, an hour or more, two other nurses marched in abreast like soldiers, with a great clumping of sabots, and knotted the corpse up in the sheets, but it was not removed till some time later. ... There you are, then, I thought, that's what is waiting for you, twenty, thirty, forty years hence: that is how the lucky ones die, the ones who live to be old. One wants to live, of course, indeed one only stays alive by virtue of the fear of death, but I think now, as I thought then, that it's better to die violently and not too old. People talk about the horrors of war, but what weapon has man invented that even approaches in cruelty some of the commoner diseases? ‘Natural’ death, almost by definition, means something slow, smelly and painful. Even at that, it makes a difference if you can achieve it in your own home and not in a public institution. This poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number...

In the public wards of a hospital you see horrors that you don't seem to meet with among people who manage to die in their own homes, as though certain diseases only attacked people at the lower income levels. ...  I have no doubt that the Hôpital X was quite untypical of French hospitals even at that date. But the patients, nearly all of them working men, were surprisingly resigned. Some of them seemed to find the conditions almost comfortable, for at least two were destitute malingerers who found this a good way of getting through the winter. The nurses connived because the malingerers made themselves useful by doing odd jobs. But the attitude of the majority was: of course this is a lousy place, but what else do you expect? It did not seem strange to them that you should be woken at five and then wait three hours before starting the day on watery soup, or that people should die with no one at their bedside, or even that your chance of getting medical attention should depend on catching the doctor's eye as he went past. According to their traditions that was what hospitals were like. If you are seriously ill and if you are too poor to be treated in your own home, then you must go into hospital, and once there you must put up with harshness and discomfort, just as you would in the army. ...

During the past fifty years or so there has been a great change in the relationship between doctor and patient. If you look at almost any literature before the later part of the nineteenth century, you find that a hospital is popularly regarded as much the same thing as a prison, and an old-fashioned, dungeon-like prison at that. A hospital is a place of filth, torture and death, a sort of antechamber to the tomb. No one who was not more or less destitute would have thought of going into such a place for treatment. And especially in the early part of the last century, when medical science had grown bolder than before without being any more successful, the whole business of doctoring was looked on with horror and dread by ordinary people. Surgery, in particular, was believed to be no more than a peculiarly gruesome form of sadism, and dissection, possible only with the aid of bodysnatchers, was even confused with necromancy. From the nineteenth century you could collect a large horror-literature connected with doctors and hospitals. Think of poor old George III, in his dotage, shrieking for mercy as he sees his surgeons approaching to ‘bleed him till he faints’! Think of the conversations of Bob Sawyer and Benjamin Alien, which no doubt are hardly parodies, or the field hospitals in La Débâcle and War and Peace, or that shocking description of an amputation in Melville's White-jacket! Even the names given to doctors in nineteenth-century English fiction, Slasher, Carver, Sawyer, Fillgrave and so on, and the generic nickname ‘sawbones’, are about as grim as they are comic. The anti-surgery tradition is perhaps best expressed in Tennyson's poem, The Children's Hospital, which is essentially a pre-chloroform document though it seems to have been written as late as 1880. Moreover, the outlook which Tennyson records in this poem had a lot to be said for it. When you consider what an operation without anaesthetics must have been like, what it notoriously was like, it is difficult not to suspect the motives of people who would undertake such things. For these bloody horrors which the students so eagerly looked forward to (’A magnificent sight if Slasher does it!’) were admittedly more or less useless: the patient who did not die of shock usually died of gangrene, a result which was taken for granted. Even now doctors can be found whose motives are questionable. Anyone who has had much illness, or who has listened to medical students talking, will know what I mean. But anaesthetics were a turning point, and disinfectants were another. Nowhere in the world, probably would you now see the kind of scene described by Axel Munthe in The Story of San Michele, when the sinister surgeon in top hat and frock coat, his starched shirtfront spattered with blood and pus, carves up patient after patient with the same knife and flings the severed limbs into a pile beside the table. Moreover, the national health insurance has partly done away with the idea that a working-class patient is a pauper who deserves little consideration. Well into this century it was usual for ‘free’ patients at the big hospitals to have their teeth extracted with no anaesthetic. They didn't pay, so why should they have an anaesthetic — that was the attitude. That too has changed.

And yet every institution will always bear upon it some lingering memory of its past. A barrack-room is still haunted by the ghost of Kipling, and it is difficult to enter a workhouse without being reminded of Oliver Twist. Hospitals began as a kind of casual ward for lepers and the like to die in, and they continued as places where medical students learned their art on the bodies of the poor. You can still catch a faint suggestion of their history in their characteristically gloomy architecture. I would be far from complaining about the treatment I have received in any English hospital, but I do know that it is a sound instinct that warns people to keep out of hospitals if possible, and especially out of the public wards. Whatever the legal position may be, it is unquestionable that you have far less control over your own treatment, far less certainty that frivolous experiments will not be tried on you, when it is a case of ‘accept the discipline or get out’. And it is a great thing to die in your own bed, though it is better still to die in your boots. However great the kindness and the efficiency, in every hospital death there will be some cruel, squalid detail, something perhaps too small to be told but leaving terribly painful memories behind, arising out of the haste, the crowding, the impersonality of a place where every day people are dying among strangers.

The dread of hospitals probably still survives among the very poor, and in all of us it has only recently disappeared. It is a dark patch not far beneath the surface of our minds. I have said earlier that when I entered the ward at the Hôpital X I was conscious of a strange feeling of familiarity. What the scene reminded me of, of course, was the reeking, pain-filled hospitals of the nineteenth century, which I had never seen but of which I had a traditional knowledge. And something, perhaps the black-clad doctor with his frowsy black bag, or perhaps only the sickly smell, played the queer trick of unearthing from my memory that poem of Tennyson's, The Children's Hospital, which I had not thought of for twenty years. It happened that as a child I had had it read aloud to me by a sick-nurse whose own working life might have stretched back to the time when Tennyson wrote the poem. The horrors and sufferings of the old-style hospitals were a vivid memory to her. We had shuddered over the poem together, and then seemingly I had forgotten it. Even its name would probably have recalled nothing to me. But the first glimpse of the ill-lit murmurous room, with the beds so close together, suddenly roused the train of thought to which it belonged, and in the night that followed I found myself remembering the whole story and atmosphere of the poem, with many of its lines complete.

    Posted by on Tuesday, November 21, 2006 at 12:09 AM in Economics, Health Care | Permalink  TrackBack (0)  Comments (19)

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