Saturday, May 17, 2014

Don't let “universal services” be turned into “safety nets”

One of the ways the political right beats the left is by being more effective at choosing the battleground of debate – by getting others to adopt their definition of what the debate is actually about.

When it comes to Medicare, unless the ALP, Greens and other centerists claim back the language, their defeat is inevitable: it may come in this budget (I hope not – I hope the ALP finds its courage down the back of the lounge), or in ten years, but it will come.

Here are a few articles written by relatively well-heeled journalists on all sides of the political spectrum.

What these articles all have in common is that they cheerfully describe Medicare as a safety net – and many, many on the left also do so when they're defending it.

My cluestick: “universal” and “safety net” aren't the same thing.

Safety net” means “we reserve a minimum and usually inadequate standard of care for the poor”.

Universal” means “everybody”.

Two things happen when “universal” is ghettoed into “safety net”:

  1. The definition of what should actually exist inside the safety net is in the gift of the powerful.
  1. Because of (1), people will be marginalised.

The marginalisation won't, however, be the careless marginalisation that happens when lawyers define the mission of a charity (I've written about this here). It'll be a matter of deliberate policy: the government will pick winners and demonise losers as an exercise of power.

It's already on the agenda. If you don't believe me, read through the Commission of Audit report. It's all about picking winners and demonising losers.

There's another point to be made: narrowing what Medicare actually offers is also deliberately destructive: “this service is accessed by too few people, and is becoming expensive to deliver, so we are going to pass it over to the private sector”. The previous blog post I linked above provides an example of this in action.

By reducing the mission of Medicare, you reduce its efficiency and effectiveness at the edges. The edges get trimmed away – only to reveal the next edge, the next target. This isn't accident, it's strategy, with its aim being the dismantling of the public healthcare system.

Characterising Medicare as a “safety net” is an exercise in propaganda. It redefines the mission of Medicare in a way that is exclusively to the benefit of the radical right, because “safety net” and “universality” are exclusive. The same goes for things education, unemployment support, pensions and disability services.

Mainstream journalists – who approach the medicare debate from a standpoint of being well-paid and well-insured – adopt the language of “safety net” because they lack personal experience at the margins. Politicians of the right do so out of strategy; and politicians of the left do so because they feel powerless to drag the debate back onto their own battleground.

Often, battles of language are trivial, but the confinement of social rights into the “safety net” ghetto is an important battle that has to be fought, or the left will lose. 

Tuesday, May 13, 2014

A star and a compass

After nearly five years in the somewhat intense world of advanced medicine, you get a lot of experience of all levels of the training of medicos, from students dutifully trailing behind specialists, all the way to “I just got a really good posting, goodbye”.

In the middle of this there are a lot of medical registrars. A lot of them: we've had them in gastroenterology, cardiology, immunology, renal – not to mention the suffering and sleepless registrars that staff the emergency departments, and the harried, apologetic registrars in ICU.

Some seem to be merely meat in a sausage-machine of training, but very occasionally, from the patient side, you get to see the genius, the stand-outs that you know can do well, because.

Because they're more thorough than the rest.

Because they care more than the rest.

Because they know more than the rest.

Because they fear more than the rest.

It takes its toll.

You, the public-hospital registrar of yesterday's visit, you are suffering and we see it. You've got too many patients who will die before you get to replace “registrar” with “specialist”, but since it's your third return to the same place, Ms T and I suspect which specialty has caught your passion.

You're young – I don't do well at guessing age, but you're about 30 – and your hair is greying too fast.

Your face should be relatively unwrinkled, but you scowl at your own decisions and doubt your reassurances that things are going well. So it's not.

You try to cover your forehead with your hair, because you don't want us – the patients and their carers – to see how much you wrinkle your forehead when you're fretting about what will go wrong next.

We see this, because we've seen you when our lives were at their darkest.

You once hugged Ms T when you apologised that you couldn't do more.

You fret and frown and add another grey hair when choosing between an X-ray or a CAT-scan (one is less sensitive, the other has more radiation).

You worry and apologise and fret and hug, you think and calculate and worry some more, and it's makes you better and kinder and more loved than those who live their lives in a sausage machine.

You're going to do good, and with a little luck and opportunity, you will be great. But it's going to hurt.

You can't save everyone, and every death will hurt, because that's already the story in your eyes.

But there's this: there will be wins and lives saved and families preserved. Lovers will love, children will grow to adults, and their lives will be your reward.

Your care, your fanatical attention to detail, your shining intellect – one day, a leap of intuition and a guess that “we should check that” will mean someone will send you presents each year because they or someone they loved got a life they didn't expect.

Treasure that, and make that your star and compass.

Ms T and I know that it's more than likely, one day, that someone will have to let a hammer fall. Know that if it's you that pronounces the dread words, says “I'm sorry, but ...”

If someone has to say it to us, we'd not just forgive you if it were you, we'd love you for taking the burden of saying it. We'll still know that we were lucky to know you, because we know you'll do good in the world.

But it's a burden to you, and we know it. We hope the burden doesn't break you, because in your future, the patients you save will love you for it.

We do. 

Sunday, May 11, 2014

Bravery: Friends are better than "narratives"

When friends talk of strength and bravery in the face of illness, it's a blessing, even though Ms T and I aren't brave.

Well, perhaps we are. Perhaps I am. I try. I get there sometimes.

There are the other times, though. The times I'm not brave: wishing things were otherwise at 2am, wanting a life less lonely, hoping the latest lump is nothing (it was nothing, this time), lost in the concentric circles of cascading cares.

When an old friend like Sarah (not her real name and not the same one as either of the other two) has a longish public conversation with me, spending most of it with at least one arm around me and often both, and talks of bravery, it's a support and a blessing. I know Sarah's battles – with cancer, a long time ago – her recovery, and she knows ours, and when she blesses our courage, it's in the context of a friendship of more than twenty years. Were I to break in the face of the enemy, falter in my resolve, cry in a corner, whatever: Sarah won't despise me for it, because she's a friend.

There's another bravery out there, and it's not a support, it's a burden.

It's the bravery not of a friend's arms, but of a pop-culture narrative. The pop-culture bravery, the “plucky survivor” narrative, given extra human-interest colour by the “never-say-die” carer who juggled everything, held it all together, smiling at the five-year mark as they embark on a new journey. Hooray.

Behind the cheery smiles and the media-constructed narrative are imperatives that have hearts of flint and do not forgive: “you have to believe you can win”, “you have to keep smiling”, “you have to be strong”.

In this world, dignity is a demand, rather than the real-world's desperate fight to look normal when you're bedevilled and in turmoil.

I can't be perfect or strong or brave, and I'm not even the one who's sick here.

The burden of perfection, living within the narrative, is imposed by people who lift not a finger to help Рthe TV producer who sees the perfect tear-jerker story in a still-youngish, still-photogenic Dick and Jane; the inspirational celebrity whose story is written in easy clich̩ by a lazy journalist (with a link for donations to a foundation at the end); today's success story who is mourned a decade hence with not even a nod to the misery that accompanied the end.

I'm not that brave, really I'm not. I can't live a narrative, only a reality. My imperfections abound and rebuke me at two in the morning.

But I have friends, and I hold them closer than the media narrative. Friends don't merely talk of strength and bravery: they are the means and the arms and the muscles and the love. And while the cold screen in the corner of the living-room chatters about a bravery that doesn't exist in real life, I'll be a loving coward and hope it's good enough.

If I can merely be good enough for Ms T and the loving friends that hold me and care, it's enough.