/ 6 October 2014

Patience in the waiting room — the doctor will see you just now

Patience In The Waiting Room The Doctor Will See You Just Now

‘The waiting room” is a spatial, temporal and metaphorical concept. In Southern Africa, and across political borders to our north, the idea that we are in the waiting room of history has deep roots in political, scientific, economic and cultural discourses and accounts.

Instantiations of waiting are all around us: we are waiting for the chimera of economic development, for the cure of freedom, for the treatment of equality, for the jobs needed, for the nutrition distributed, for the epidemic halted, for the drugs supplied, for the electricity restored, for the equipment fixed, for the nurses to arrive, for the doctors to see us.

In 1940 Gerard Sekoto painted The Waiting Room. A woman, a man, a baby, sit waiting. The man leans into the woman. She sits upright, expectant, vigilant perhaps. The baby’s arm, naked and vulnerable, emerges from the blanket holding her to her mother’s back. They are young. He wears a hat. She wears a doek. They are not in the first row. They have a long wait ahead.

Since Sekoto’s painting, completed in the midst of World War II, images in art galleries, newspapers, medical journals, missionary accounts, public medicine tracts and revolutionary treatment manifestos have depicted the injustice, futility, wastefulness and hopelessness of the waiting rooms that shape South African and continental experiences of biomedical systems of “healthcare delivery”.

The filing cabinets of our minds are filled with these images, sometimes of ourselves and people we know, of people queuing, spending hours and days and more inside them, being patient, waiting.

What is it to be a patient; to be patient? The wait is always longer if you are poor and, if you are a very young person, or an elderly person, or a caregiver, usually a woman. Powerful people don’t sit out hours and days in waiting rooms. I am not thinking here of the wait in the rooms of a priest or a private dentist, at a taxi rank, at the bank, in a temple, or at a hair salon. In these cases the wait is not interminable and is rewarded in some way.

Medicine transformed
The “waiting room” I want to understand is a liminal place, a place in-between, a place of ritualised passivity, dependent on the co-operation of patient, the supplicant. Recently a Competition Chronicle headline blared “South Africa – healthcare inquiry finally out of the waiting room”, in a piece about competition in medical services, asking whether the National Health Insurance plan will deliver us from costly and yet iniquitous healthcare. Will this place, the waiting room, a central trope of our experience of medicine in the 20th century, be challenged and transformed in the 21st century?

It is hard to analyse waiting and being the patient because this kind of performance of selfhood is so expected, so thoroughgoing and so naturalised for a great majority.

At the recent University of Cape Town conference on medical humanities, the second major gathering of this sort in South Africa in the past two years, people from across the health and medical disciplines, clinicians, artists, humanities scholars, from all areas of research, gathered to ponder what kind of agenda we can hope for in bringing together disciplines currently set apart in research, educational and practice spaces.

Organised around four streams, with papers, interventions, provocations, case studies, performances and research summaries, this conference addressed paradigms, pedagogy, practice and potential, with the last focused on the first 1 000 days of human life.

I was asked to speak in the opening session and it seemed fitting to begin with the “waiting room”. As a historian of medicine and health I want to know how and under what conditions public clinics, hospitals and health professionals designed the waiting room and how “patients”, the key actors in that space, emerged.

I thought about healers coming to people’s homes and caring for them there in the not very distant past. I thought about the exigencies of the modern hospital, and all its equipment and technology, but also the reality of the low-tech and routine service that patients receive for most of their treatments after all those hours in the waiting room.

Sensory training
I recalled the account of a doctor friend just returned from Brazil where she interacted with general practitioners who visit patients in their rural homes as part of a widespread and well-functioning system of care. I read Dr Abraham Verghese’s work, insisting on time spent – on touch, on listening and sensory training and the ethics of care – as he teaches Stanford University medical students their clinical method.

I thought of the doctor visiting the patient’s home, and being offered hospitality. I thought about the powerful narratives of healers washing the feet of their patients, rubbing them dry with their own hair.

One of the most widely reproduced and best known images of a doctor, The Doctor, painted by Luke Fildes in 1891, exemplifies the caring family doctor who sits at the bedside of a dying child hour after hour, through a long night. He has no cure to offer, but yet he offers his presence and his witness to the value of this life.

Verghese wrote in the Atlantic in 2009 that the powerful American Medical Association pressed this image of care and ethics into propagandistic service in the post-World War II period, against then-president Harry Truman’s plans for a United States public health system.

The association used the image as an exemplar not of care but of individuated medicine, which it argued would be threatened by public healthcare systems. It is particularly painful to read the views of this reactionary body today while analysing the reality of public health-care in many parts of our country and region.

To understand the impact of waiting on social power I read a paper on immigrants from across our borders, who know they have a second journey to begin when they arrive here, spending weeks and months and more in the South African home affairs department’s version of the waiting room.

Valiant efforts
I read public health journals and papers analysing waiting times; loss to follow-up and care; stock-outs; staff apathy and demoralisation – and in these papers emerged accounts from the past 20 years of efficacy in time and motion studies; of patient trackers and navigators; and of the uneven but valiant efforts to shorten queues, save money and time and address patient rights.

A young person embarking on lifelong HIV treatment may spend many years in the waiting room, and so will many women during the cycles of their birth labours and their postnatal care for the young; so too will elderly people who need chronic medication for diabetes; and even acute sufferers – people wounded in traumatic events – languish in the waiting rooms we have created.

Scholars leading the field of medical humanities globally – Arthur Kleinman, Shonu Das, Verghese, Margaret Lock, Løchlann Jain, and artists, physicians, psychiatrists, nurses, anthropologists, cultural and social theorists – have illuminated critical health questionings as they study pain, wellness, suffering, healing, evidence, care, agency, knowledge and health rights.

Subjection and objection
Historians in the past 40 years, from Michel Foucault and Roy and Dorothy Porter in Europe to Emma Vaughan and GL Chavunduka in Southern Africa have drawn attention to the history of subjection and objection in our search as human beings for livelihood and wellness. While biopolitics offers an explanation of post-18th-century medicine’s creation of specific human subjects, I find necessary and plausible a longer history of thinking about waiting and patience and doctoring.

One of the most widely read, translated, inspiring and portable texts in African spaces, Bunyan’s Pilgrims’s Progress, imagines a pilgrim who is active in his suffering and who pursues redemption and freedom from pain and horror with every fibre of his being. As Isabel Hofmeyr has shown in her magisterial book The Portable Bunyan: A Transnational History of The Pilgrim’s Progress (1678), audiences and readers around the world responded to and shaped a vision of the seeker and the sufferer – resilient, exhausted, burdened, but mobile, directed, never patient. Taken up across so much of the continent, how has that vision of African suffering agency been replaced today by such pervasive representations of passivity, limbo, immobility?

Working in a different vein, but alive to the impact of Bunyan’s texts in Europe, the two Porters’ study of how people “became patients” and entered the waiting room is instructive in our setting. Their book, Patient’s Progress: Doctors and Doctoring in Eighteenth-Century England, shows the slow and complex way in which “patients” became the co-construct of modern medicine.

Etymologically the word “patient” meant any sick or suffering person but today the word implies having being placed “under a doctor” or medical practitioner.

In their study, the Porters depict European society at a time when it was overshadowed by illness, pain, epidemics and the constant threat of death. Self-medication, healers, community experts and medical services were connected through complex and rich sociological bonds. At this time patients and their doctors began to set in motion a privileged but also very precarious relationship.

By the late 20th century, when the self-perceptions of patients had become what they term “medically contaminated”, the Porters ask whether patients can be studied only inasmuch as they have been made visible (or, rather, invisible) by the “medical gaze”. Their work urges us to journey to a time, not that long ago, during the contested professionalisation of medicine and the birth of the clinic. They offer ideas for how doctors can subvert this gaze and how nurses and clinics can dismantle the waiting room as the staging area.

Porter and Porter show that to create the waiting room and “the patient” took effort and time, and the process was not self-evident.

Radical rethinking
The interests and agency of carers, sufferers and seekers was not easily thwarted, and 18th-century versions of the Treatment Action Campaign illuminate the possibility of a radical rethinking today.

In tracing the contours of this process of medicalisation in Southern Africa, Gordon Chavunduka, a Zimbabwean sociologist and healer, accounted for the rise of professionalisation in African medicine, and the long conversation between African and Western and Asian therapeutics in his three scholarly works on the subject.

His writing, and that of the Porters, alongside Ghada Karmi’s work on Arabic folk medicines, Julie Parle’s sensitive study of the search for mental health in colonial Natal, Nancy Hunt’s lexicographies of childbirth in the Congo and the suturing of plural medical practice there and in Ghana, and Julie Livingston’s book about of the forms of oncology treatment in Botswana, allow us to see that dismantling the waiting room will be herculean, and it is the work of the historian, the person seeking treatment, the psychologist, the civil servant, the grandfather, the clinic manager, the accountant, the platinum miner, the poet, the cook, the driver, the voter and the elected official, just as much as it is the work of the nurse, the doctor and the patient.

Dr Catherine Burns is a historian and leads the medical humanities project at the University of the Witwatersrand, where she is based at the Wits Institute for Social and Economic Research. Gerard Sekoto’s painting, The Waiting Room, is reproduced by kind permission of the copy-holders, The Gerard Sekoto Foundation/DALRO