I have just returned home after a health-related immersion of over 10 weeks as a patient and participant-observer in an NHS hospital and then in a private sector care home. Quite an experience. A few reflections.
Unlike most immersions this one was not vulnerable to distortion by special behaviour put on by the ‘hosts’ for the immersee. I reflected on hospitals as species of total institution, a term used by Irving Goffman in his 1961 book Asylums: essays on the social situation of mental patients and other inmates which is based largely on mental asylums and prisons. Total institutions present conditions many of which are to varying degrees found not only in asylums and prisons, but also in boarding schools, orphanages, hospitals, care homes, barracks, ships, detention centres, concentration camps, ashrams, monasteries, nunneries and some cults. Those who are inmates are within the institution effectively lowers and have special names – inmates, crew, passengers, patients, residents, boarders, prisoners, detainees, devotees and more while the staff who manage them are uppers, variously supervisors, teachers, warders, guards, doctors, nurses, spiritual leaders, mothers and fathers superior, and also crew in some contexts. So I was a lower, an inmate patient or resident, and doctors, nurses and other hospital and care home staff were my uppers.
The NHS staff were great, very busy and with a friendly esprit de corps. They were from many countries – Albania, Romania, South Africa, Cote d’Ivoire, Uganda, Nigeria, New Zealand, Indonesia, the Philippines and more, and of course the UK. One night shift was staffed by all Filipinas who chattered away in Tagalog. The rich and varied experience staff brought to the job, and what some had to put up with in what looked like horribly uncomfortable PPE was eye-opening. (though in my ward they were not in the full rigout).
Lowers’ contact with others outside the institution is often limited and tied to fixed hours in part for the convenience of the staff. The evening meal or snack as it was in the care home was a little after 5 p.m., rather early for obvious reasons. I was lucky at first that my wife and son, Jenny and Ajit, could visit me and bring me things in the first days before lock-down.
Like inmates in other institutions, I built up a stash of things which I squirreled away. Jenny sent me a cake. Ajit brought in some vodka in a bottle labelled green tea (to be drunk with fizzy vitamin C). The laugh was on me when I was thirsty and took a mouthful believing the label and then had no option but to swallow it. Interestingly Goffman found vodka in mental asylums, perhaps because it looks like water and does not affect the breath as much as other drinks, or so they say.
Many total institutions insist on and often provide a uniform dress for inmates. Think of nunneries, monasteries, some prisons, boarding school. There was a default dress which was hospital pyjamas which I wore when my own clothes ran out. They were good. Interestingly the staff roles were differentiated by the colour of dress – at least four of these. Doctors and the basic cleaners largely wore their own clothes.
The experience as a lower was salutary and took me down a peg or two. My upper characteristics were unimportant. I was just another body, another patient. Others in the all-male ward where I spent much of the time were worse off than me. At least half were diabetic and often overweight. One opposite me despite having had both legs amputated above the knee was full of jokes and good cheer. It put me in my place, to realise how lucky I was.
At first, I was marginal. Newcomers to the company of other lowers often begin marginalised and have to build relationships with other lowers, some of whom can have developed relationships with the uppers, notably in this case doctors, nurses and others with nursing roles. In the ward my bed initially was physically on the fringe. I was reminded how I always wanted to return early to boarding school on the first day of term in order to ‘bag’ a good bed not least because which bed you had limited or extended what you could do and who you could interact with after ‘lights out’. In the ward the initial position of my bed was a big disadvantage. As a newcomer I had no choice. I had no window near and no view and from partial deafness could not hear the conversations of others, let alone take part in them.
Weeks later, by virtue of being one of the longest inmates and seizing an opportunity to get a bed near a window, the view was better but outside just brick and cement except for a narrow slit with sky and sea. How I treasured that, and the sunlight on my bed every day for 10 minutes just before six in the evening. But nothing green in sight. How much I normally take for granted!
Some lower features were much in evidence, most of them noted by Goffman. He didn’t use the upper-lower language but differentiated staff and inmates. On entry there was a process of what he calls stripping – in my case this was not marked but included an identity on a white plastic wristlet, removal of some clothing, and possessions for which there was a receipt, my medicines locked up and the key held by nurses, hospital pyjamas (not at all bad). However, for the two operations I had, I particularly did not like the obligatory gown which does up at the back. Special language was used for us patients, not unkindly but reflecting upper-lower status – we were after all immobile on our backs while the staff were upright and mobile. We were ‘‘we’d’ – normally used with children – as in ‘ how are we this morning?’ and ‘did we have a good night?. It was touching to be ‘darling’, my darling’ and ‘my love’, terms used by all staff except doctors and by some of the younger men and the cleaners. These last did an amazingly thorough job and some were volunteers as part of the Covid crisis response.
Total institutions typically have boundaries which inmates cannot cross and within which they are confined. In our case after the first few days when Jenny and Ajit could come, we had no visitors from outside. Mobiles were a godsend. Isolation was less of a burden because impressively, every bed had its own TV with many programmes, including Al Jazeera. Well done NHS.
Total institutions take over responsibility for all bodily needs – food, clothing often, sleeping arrangements – and have daily routines. Boredom can be a problem, so the routines assume importance. You need to know what these are – the time of the ward round, the times when tea or coffee are brought round, and the times of meals. Those in total institutions have usually no say over their food. But the NHS not only gave two choices for everything for every meal, but the food was damn good and nicely varied. What I received was always without fail what I had requested. I looked forward to meals more than usual.
I take away two unforgettable experiences. The first was my second operation, an amputation below the knee. I was awake throughout and did not find the music particularly congenial. I asked whether we could have some Mozart. While the Mozart was playing it was suddenly accompanied by a loud sound of sawing, as bizarre if not gruesome a juxtaposition as one could imagine. Later when I met the surgeon, she (the entire team were women) wondered why I had not chosen Beethoven, and we agreed that loud Beethoven, perhaps the Ode to Joy, would have been better.
The other unforgettable experience was the wonderful and touching cards, videos and big sheet with many messages from so many of you, both from IDS and beyond. There is no way I can reply to all of you or adequately express my gratitude. They kept my spirits up and gave me a lift. I am keeping all those messages and will treasure them for the rest of my life. Thank you all, thank you. Robert (now finally back home)
You do not have to be good.
You do not have to walk on your knees
for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body
love what it loves.
Tell me about despair, yours, and I will tell you mine
Meanwhile the world goes on.
Meanwhile the sun and the clear pebbles of the rain
are moving across the landscapes
over the prairies and the deep trees,
the mountains and the rivers.
Meanwhile the wild geese, high in the clean blue air,
are heading home again.
Whoever you are, no matter how lonely,
the world offers itself to your imagination,
calls to you like the wild geese, harsh and exciting –
over and over announcing your place
in the family of things.
Everyone suddenly burst out singing
And I was filled with such delight
As prisoned birds must find in freedom
Winging wildly across the white
Orchards and the dark-green fields; on; on; and out of sight
Everyone’s voice was suddenly lifted
And beauty came like the setting sun.
My heart was shaken with tears; and horror
Drifted away…O but everyone
was a bird, and the song was wordless; the singing will never be done