Who is the NHS for? Not me!

On radio 4 early on Sunday morning I heard reported that 40% of the British population think people with disablities are ‘work-shy’. The figure comes from a recent survey of public attitudes to disablity called Access all areas. It doesn’t use the phrase ‘work-shy’ on the report, it says, “40% felt disabled people turned down job offers even when they were physically capable of doing them.” I was shocked. Obviously people turn down work they’re capable of for all sorts of reasons, but the figure shocked me because I think our attitudes to disability are symbolic of our attitudes to ourselves. I’m a GP in an inner-city practice with exceptionally high levels of deprivation looking after a lot of people with disabilities. Work-shy isn’t something that comes to mind when they struggle down the corridor on their crutches or sit at home all night after a stroke waiting to call me rather than bother the ambulance, or when they come in to see me for a review of their depression and apologise for their dishevellment – a consequence of being too depressed to eat, sleep or wash properly for the last month.

The answer to the question, “Who is the NHS for?” seems obvious, but most people reading this will have had little contact with the NHS and little experience of serious illness or disability. Illness doesn’t affect everyone equally. By far the unhealthiest years of our lives are at the end, and we’re pretty vulnerable at the beginning. In between, during our most productive years we are on the whole, pretty ignorant of illness and disability.

Conditions that affect us in our prime such as depression, learning disabilities, drug and alcoholism, epilepsy and so on are under-represented in our media saturated world of idealised conceptions of healthy people. The vicious cycle of illness, disability and poverty further alienates them, ‘the unhealthy poor’ from us, ‘the healthy’.

Combined with a historically unparalleled rise in prosperity over the lifetime of most people in this country, it is very easy to avoid thinking about vulnerability, including our own.

David Bell, president of the Institute of Psychoanalysis and a consultant psychiatrist, warns of the dangers:

Our relationship with awareness of our own vulnerability is far from comfortable – we have a natural tendency to locate it in other people – it is he, not me, who is in need, it is she, not me, who is vulnerable.

We maintain this attitude towards our future risks as well. Even if we’ve been fortunate enough to enjoy good health for most of our lives, we’ll all need medical attention in our latter years. On a few occasions this year I’ve spoken publicly about the incidence of disease and disability in old age, some of the uncomfortable statistics are as follows:

1 in 3 of you will spend your last years with some form of dementia

1 in 4 of you will experience mental health problems and 1 in 4 of you with 2 or more chronic diseases will also be depressed

1 in 10 of you will have cancer once you’re over the age of 60

Almost 1 in 4 men and 1 in 6 women over the age of 75 will have some form of heart disease.

About 1 in 7 men and 1 in 9 women over the age of 75 will have diabetes. If you are from a SE Asian background the chance will be up to 6 times higher.

1 in 5 men and 1 in 6 women will have some form of painful arthritis

Almost one in four men and one in five women aged 45 can expect to have a stroke if they live to 85.

Not only will you be diseased up to the earlobes you’ll also be drugged up to the eyeballs:

On average people over 60 received more than 42 prescription items in 2007. In 1997 they received on average only 21.

1 in 16 hospital admissions are due to adverse drug reactions and 2% of people admitted die as a result of these reactions

If any readers want to try reading these statistics out to their friends I expect you’ll have the same response that I had: people beg you to spare them the depressing details or they stick their fingers in their ears. When I debated with Civitas (the think-tank dedicated to seeking intellectual justification for the conversion of the NHS from a public service to a free market) one of the audience members said that GPs are no longer necessary because you can just put your symptoms into Google to get a diagnosis and then choose your specialist for treatment. What he means of course, is not that ‘people’ will have no need of a GP, but that he will not need a GP. His response is a real world example of what philosopher Slavoj Zizek describes as ‘a drive not to know’,

Another lesson of psychoanalysis is that, contrary to the notion that curiosity is innate, that there is deep inside each one of us a Wissenstrieb, a ‘drive to know’, there is, in fact, the opposite. Every advance in knowledge has to be earned by a painful struggle against our spontaneous propensity for ignorance. If there’s a history of Huntington’s chorea in my family, should I take the test which will tell me whether or not (and when) I will inexorably get it? If I can’t bear the prospect of knowing when I will die, the (not very realistic) solution may appear to be to authorise another person or institution whom I trust completely to test me and not tell me the result, but, if the result is positive, to kill me unexpectedly and painlessly in my sleep just before the disease’s onset. The problem with this solution is that I know that the Other knows the answer, and this ruins everything, exposing me to gnawing suspicion. Slavoj Zizek Bring me my Philips Mental Jacket

For David Bell, this ‘gnawing suspicion’ can be revealed in his patients who present with conditions such as schizophrenia and narcissistic disorders and also at the societal level where,

this projective system has a drive of its own: as it gathers momentum it acquires contempt, providing the psychological soil for destructive social processes such as racism or homophobia to germinate.

In a remarkably foresighted paper he wrote in 1999 in the journal of Psychoanalytic Psyochotherapy, titled Primative State of Mind, he explains the social implications:

But, Reich argued, [in his book The Mass Psychology of Fascism], fascism also reflects man’s deep aspirations and it cannot be fully understood without appreciation of the fascist mentality and its deep
roots in the unconscious. Reich explored how, through identification with a tyrannical (Nazi) figure, masses of the oppressed population were supported in their wish to project their own hated vulnerability elsewhere. The Nazi propaganda machine provided objects for this projection, namely Jews, gypsies, homosexuals and blacks. It is thus their own hated vulnerability and helplessness which they then sought to annihilate through extermination of these people. This is, of course, not meant to be a total explanation of fascism, but if it is not included in the broader social and political understanding of fascism, something essential is lost.

Like the ancient Greeks we have made a virtue of health and ability and infused them with moral status, so that when we ourselves are ill, disabled or vulnerable whether due to cancer, poverty or loneliness, our natural inclination is to ask, “why me? what did I do to deserve this? I never thought it would happen to me!” We project this perceived moral weakness on others in order to make ourselves feel better. I’ve explored this idea in a previous post: Is Socialised Medicine Evil? which discusses various right wing trends that link wealth and health with moral good, “We deserve to be wealthy and healthy because we are good, they deserve to suffer because they are bad.” Bell predicts our present state of affairs,

The cuts express an ideological assault on the concept of welfare – originating with Margaret Thatcher and now escalating violently. This ideological position can be characterised as follows: the welfare state does not provide people with the basic necessities of life as part of a duty of state but instead is a mechanism by which people are disempowered, creating in them a helpless state of invalidism. The “have-nots”, instead of “getting on their bikes” and competing in the marketplace, stay at home and whinge for the nanny state to do something for them. Namely, to have one’s basic needs met is to be treated as if suffering from a state of infantile dependence and to be dominated by a delusion of an inexhaustible supply of provision.

In this kind of thinking, or more properly non-thinking, the world collapses into simple binary categories – “us and them” – and all complexity is lost.

Those on welfare become just “scroungers”. Worst of all, many who are legitimately entitled to benefit identify with this propaganda and collapse into despair. The nanny state slogan expresses this perverse logic and hatred of vulnerability.

The propaganda is most effective when it is internalised, sentiments echoed by the Archbishop of Canterbury last month, talking about government plans to force pople on welfare to do voluntary work,

people who start feeling vulnerable feel even more vulnerable as time goes on, that’s the kind of unfairness that I feel. People often are in this starting place, not because they’re wicked or stupid or lazy, but because circumstances have been against them, they’ve failed to break through into something and to drive that spiral deeper, as I say, does seem a great problem.

I see this in my patients every day, they really are driven to despair, believing that others see and treat them as a burden on society, they internalise this as guilt and shame which leads to misery and anxiety and in the worse cases, suicide. Returning to the BBC survey of attitudes to disablity,

People in lower income groups were found to be less compassionate on the issue of disability than skilled people, with older people sometimes more intolerant than the young.

The shocking conclusion is that the ideological assault on the welfare state, including the NHS is made likely to succeed because in doing away with the institutions designed to protect us when we are most vulnerable we are both denying and symbolically doing away with our own vulnerablity.

What’s needed is a renewed compassion for others and ourselves.

See also

Today’s Britain: where the poor are forced to steal or beg from food banks. Guardian 27/10/2014

Language is a weapon used to make ‘others’ of people in poverty. Joseph Rowntree Foundation. April 2013

The ‘scounger’ myth is causing real suffering to many in society. LSE blog. April 2013

Owen Jones, Independent 13.12.2011:

We don’t even really talk about the unemployed anymore; they’re more likely to be “people on benefits” defining them not by lack of work, but by reliance on taxpayers’ money.

John Harris, Guardian 01.04.2013 :

We have to talk about why some people agree with benefit cuts

Truth and Lies about Poverty. Pocket Guide

Scroungers, Scumbags and Soaring Welfare Costs: excellent analysis about where the money is going by FlipchartFairytales

Benefits in Britain. Separating the Facts from the Fiction. Guardian