Friday, 8 September 2017

The Man At The Bus Stop

In October 2013, 47 year old Neil Jones was hospitalised in Christchurch Public Hospital. He had severe alcohol-induced hepatitis - inflammation of the liver.

Three weeks later, gastroenterologist Dr Richard Gearry decided that, despite having severe jaundice, Jones' condition had stabilised and he was faking his symptoms in order to stay in hospital.  Gearry ordered Jones' discharge.  Other staff expressed disquiet about this decision in light of how ill Jones was and the fact that he was homeless.

Jones was taken by hospital security to a bus stop near the hospital, and left there.  He was wearing hospital pyjamas because he had soiled his own clothes.  He lay on the ground at the bus stop for six hours, severely jaundiced, barely coherent and unable to walk.  

The hospital’s security staff were instructed to tell members of the public who expressed concern about Jones, that he was alright.  He was eventually brought back into the emergency department but was not reassessed or readmitted.

Instead, police were called to remove him from the waiting room and to issue a trespass order - i.e. order him not to return on pain of arrest. The police officers did not question this and delivered Jones to the City Mission who took him in, despite having serious concerns about how extremely ill he was. 

The Mission asked the police officers for an assurance that they would take Jones back to hospital if he deteriorated.  When Jones began vomiting blood, the police were called and after a 2 hour wait, the Mission phoned for an ambulance.  Jones was readmitted to hospital and he died there 2 days later.

Neil Jones had become an alcoholic after his partner's suicide in 2008 and at his worst was said to have been drinking 3 litres of vodka a day. How he managed to afford to buy that much is not known.

What is known is that he wanted to stop drinking but couldn't do it on his own and there is a shortage of places for alcohol and drug rehabilitation in Christchurch because of government funding cuts.  When he tried to get onto a rehab programme in late August 2013 there was a long waiting list and he started drinking again. 

Because of his severe alcoholism, his family and his partner had taken out trespass orders against him, which had left him homeless.  He was in the grip of a powerful current of extreme adverse circumstances and was unable to extricate himself from it. He was drowning and he needed a life line. 

When he was first hospitalised, he had not eaten for 3 days and was severely constipated - to the extent that his breath 'smelled faecal' according to nurses. 

During his stay he was often drowsy and could not follow instructions. On the day of his discharge Jones soiled himself and the conclusion was he was doing that deliberately in order to stay off the streets even though he was severely jaundiced and the fact that bladder dysfunction along with reduced GI motility and loss of sphincter control leading to constipation, diarrhoea and incontinence are all features of advanced liver disease. 

I don't know what tests were done on Jones or what treatments he received. What I do know is that when a person's liver is profoundly compromised, waste products that are normally filtered out by the liver build up in the blood stream and can cross the blood-brain barrier resulting in one of liver failure's most horrible complications - hepatic encephalopathy.  

Hepatic encephalopathy can cause intellectual impairment, confusion, irritability, loss of control of bodily functions, drowsiness and ultimately, if untreated, it results in coma and death.  

The symptomatic treatment for it is the use of powerful laxatives to clean out the bowel and reduce the build up of neuro-toxins in the blood. These laxatives can cause explosive and uncontrollable diarrhoea.  

Another complication of advanced liver disease is variceal haemorrhage - which is what ultimately killed Neil Jones.  Cirrhosis - scarring of the liver caused by chronic inflammation - causes an Increase in pressure in the portal vein system which takes blood from the intestines to the liver. 

This portal hypertension results in enlarged and weakened veins in the oesophagus, stomach and rectum. As portal hypertension increases, these varices can rupture, causing internal bleeding, which will result in death if especially severe and/ or untreated.

The other major player in this end stage liver disease drama is hepatorenal syndrome. The kidneys can fail because of vasoconstriction as a consequence of the disturbances to systemic circulation caused by portal hypertension. 

The only way kidney function can be protected long-term is with a liver transplant or if the patient has sufficient healthy liver cells and can be kept haemodynamically stable until the liver is able to regenerate enough for systemic circulation to improve. 

However, the reality is that if portal hypertension is severe enough to cause varices and ascites (fluid leaking from blood vessels and liver which builds up in the abdominal cavity) the disease has already progressed to the point where a liver transplant is the only hope.

Liver transplants are hugely expensive and there are too few organ donors; the only hospital which performs them is in Auckland; to get onto the list you have to be judged to be a suitable candidate physically and psychologically, you must be able to be at the hospital within a few hours of a liver becoming available, have a person who can accompany you, and be able to live near the hospital until all the postoperative care is completed, which may take weeks.

That means if you are an alcoholic, if you are homeless, poor or you are judged for some other reason not to be a suitable candidate for transplantation, you will die.  In fact, most people with advanced liver disease die.  Once active treatment ceases, they are sent home to die or they go into a hospice.  

For a man with advanced liver disease to be dumped at a bus stop in hospital pyjamas is so unthinkable it is hard to write about it without anger taking over. 

It has plunged me back into the storm of emotions I felt when I watched my younger brother die from liver disease with all of its many awful complications - refractory ascites, oesophageal varices, hepatic encephalopathy and hepatorenal syndrome. He was not in the same situation as Neil Jones but, like Jones' family, we were left with many unresolved questions about his treatment - especially on discharge. 

Another factor in Jones' tragic story is the extent of the pain that he may have been experiencing.  Pain management for cirrhotic patients is hugely problematic in that opioids cause constipation which increases the likelihood of hepatic encephalopathy, and non-steroidal anti-inflammatories can cause renal failure and gastric bleeding.  The only drug judged to be safe is paracetamol but in overdose paracetamol is acutely hepatoxic and what constitutes an overdose for a cirrhotic patient is hard to measure so it is prescribed in such small doses it is next to useless as an analgesic for severe pain.

Neil Jones went into hospital already carrying the label of hopeless alcoholic and it does seem he became a victim of that undercurrent of moralism which so often accompanies it.  In addition to being desperately ill, poor and homeless, he had no-one to act as his advocate - i.e. no-one the hospital staff were immediately answerable to.  

if he was suffering from mild to severe episodes of hepatic encephalopathy he was not able to speak for himself or to look after his own interests.  By repeatedly soiling himself and being extremely confused he may have been seen as a problem patient by some staff. According to Doctor Gearry it was feed back from some staff which led to his decision to discharge Jones, even though other staff challenged both the medical wisdom and the humanity of that decision.

Arguably the most telling thing about this is the fact that, despite the discharge debacle, no post-mortem was carried out and the on-duty coroner decided there was no need for an inquest.  If Neil Jones' family had not complained, we'd never have known how appallingly bad his treatment had been. 

As anyone will tell you who has lost loved ones - even loved ones who were as hard to help as someone like Neil Jones - the loss is that much harder to bear when you believe there were things that could and should have been done which might have altered the outcome.

If a veterinary clinic dumped a stray dog, suffering from a painful and incurable disease, out on to the street to die, there would be immediate and extreme outrage.  As his mother has said, that is precisely what was done to Neil Jones. 

The system casually spat Neil Jones out and in so doing, it failed him so profoundly it is hard to comprehend that such a thing could happen in New Zealand.

Thursday, 31 August 2017

Will The Caged Birds Sing?

"It is said that no-one truly knows a nation until one has been inside its gaols. A nation should not be judged by how it treats its highest citizens, but its lowest."  
Nelson Mandela

The French philosopher, Michel Foucault, in 'Discipline and Punish', wrote about the move away from the old public festivals of punishment towards a sanitised, industrialised form  that is largely hidden from the public gaze. 

The old forms of punishment were public spectacles – intended to entertain as much as intimidate the populace. Only the favoured (mostly the aristocracy) were granted a quick, clean and relatively private death. 

The ancient public rituals of judicial punishment - burning, hanging, beheading, disembowelling, flogging - have been replaced by incarceration, with its persistent surveillance, separation, solitary confinement and rigid discipline.  

Prisons that were once used either to hold debtors or political opponents or to hold the accused and condemned until they were subjected to corporal or capital punishment - have become the punishment.

With the emergence of the prison as the preferred, and more 'civilised', form of punishment, the methods of killing have also become 'scientific' and medicalised in most states that still execute their citizens.

The guillotine was considered a humane death in contrast to the ways a feudal traitor would have met his end. In hanging, the length of rope and weight of prisoner are carefully calculated to ensure, if not the hoped-for Hangman's Fracture, at least a rapid asphyxiation.  In electrocution, a wet sponge is placed on the head of the prisoner to hopefully render them unconscious if, as often happens, the electric shock does not kill them instantly.  But, it is with the use of lethal injection that this attempt to sanitise judicial killing, is at its most obvious  - to the extent that the process often becomes a macabre parody of a medical procedure.

The modern, clean, high-tech penitentiary is presented as a huge advance on the chaotic and bloody bedlam of what went before.  The very term ‘penitentiary’ came about because the institutions were intended to be rehabilitative. The criminal was incarcerated, confined and isolated in small, monastic-like cells within a larger building, not just to protect civil society, but in order that the evil-doer might reflect upon, and repent his sins.

The truth is that separation and isolation, the enforcement of a rigid discipline, the removal of autonomy, the lack of privacy, the imposition of who is socialised with and when - are all punishments that strike at the very heart of what it means to be human. 

We are profoundly social animals but we did not evolve in vast swarms.  Isolation is unnatural and stressful for us but so too is over-crowding and enforced association.

Our social arrangements - when healthy - allow us to choose with whom and when to interact, and when to be alone. For most of our social evolution those arrangements were within communities in which kinship and communal ties and the normal distribution of age and experience moderated and controlled group and individual behaviour.

Most prisons dispense with all the things that help keep us social and balanced and therefore human. As such they are inhumane - intended not to rehabilitate or even just to contain - but to punish. The State exacts revenge on behalf of the actual victim of a crime.

In the recent era, it has gone far beyond that.

The 'panopticon prison', in which the incarcerated cannot escape the gaze of their gaolers, may be seen as a reflection of the growth of a surveillance society in which the citizen cannot escape the gaze of the State.  Most of us are more surveilled today than we have ever been in our history as a species. 

 The prison's rigidly imposed and enforced daily regimen and the removal of any autonomy may be seen as a reflection of the loss of autonomy as a result of the imposition, onto private lives, of the priorities, timeframes and schedules of business.  Most of us (especially the poor) do not freely choose whether, when, where or how we work.

The modern state uses the prison to hide many of its social problems. It sweeps poverty, addiction, homelessness, low educational achievement and mental illness under a judicial carpet and locks it all away behind impenetrable walls.

It also removes from the body politic, a potent source of social unrest; alienated, angry young men who have been shut out of a world which dangles the promise of status and material rewards but denies most the means to reach them.

When a society fails to provide educational and training opportunities and to create meaningful work; when it labels the under- and unemployed as a ‘feral underclass'; when it creates mandatory and longer sentences for the sorts of crimes the poor are most likely to commit - it declares a whole stratum of people to be a social problem that can be solved - in part at least - by imprisoning many of them.  

As felons, people are disenfranchised; some remain so even after release. Ex-prisoners are less likely to get scarce jobs, which cements their marginalised status and means they are more likely to end up back in prison.  

This self-fuelling system has reached its nadir in the USA where the total number of men and women imprisoned in federal and state prisons is equivalent to almost half of the total population of NZ. Young black men in the USA are more likely to be imprisoned than to get a decent education.  They are incarcerated at an average rate of over 5 times that of their fellow white Americans and, in some states, that rate goes up to twice that. 

Black women are twice as likely to be imprisoned than white women. There are more women in prison in California today than there were in the entire USA in the 1970s. Women in prison often find themselves trapped in an intersection of class, race and sex controlled by an arm of a state that has already proven itself incapable of managing that intersection in wider society. 

The number of prisons in the USA has exploded since the 1970s - a large majority of them were opened in the eighties and nineties.  What Angela Davis called the 'prison-industrial complex' emerged at the start of the neoliberal era and it has proliferated and spread its tentacles all over the developed world.

The ethnic and the social class profile of the inmates of these modern prisons is evidence that the entire system is not only racist but is intended to control those people who have been hardest hit by the rapacious, globetrotting capital of the neoliberal era. 

It is no accident that in the same era in the USA and elsewhere, there has been a massive proliferation of corporations that provide private security services, an increased militarisation of the police, and an increase in the number and confidence of armed rightwing militias.

The entry onto the scene of private prisons in the USA is a return to the use of convict labour.  In private prisons there is an economic imperative to increase profits by cutting the cost of staffing and the maintenance of buildings and of prisoners, and by making money out of convict labour. 

In the antebellum era, convict labourers were almost all black men. The chain gang's links to the abolition of slavery were as obvious as the system was cruel and oppressive.  These days in the USA the captive, hyper-exploitable prison labour force is still disproportionately black. 

Mostly prisoners work in factories hidden from the public eye but reactionary extremists like Joe Arpaio publicly parade shackled inmates wearing chain-gang style uniforms - a public reminder of an era when black men convicted for minor crimes were subjected to conditions as bad or even worse than slavery - including being literally worked to death.

The likes of Arpaio remind us that, however clean, clinical, medicalised and scientific the modern surveillance state's prisons appear to be, there's an older, brutal reality that is played out inside them.  This brutal order is allowed and even encouraged as long as it doesn't turn on the keepers - and as long as its ugly truth doesn't seep too far beyond the prison walls. 

One of the greatest ironies is that the brutality is attributed, not to the nature of the institution, but to the pathological nature of its inmates.  The truth is not that inmates are all predisposed to behaving badly, but that the system places barriers to, and often prevents them from behaving well.  Furthermore, it is intended to do just that in no small part because prisoners who behave badly while inside and once released, serve to justify the existence both of the prisons and of other examples of the surveillance state. 

In all of this NZ is nowhere near as bad as America but that’s more a measure of the enormity of the USA's failures than it is of our successes. 

Our society creates and perpetuates the conditions in which some people are more likely to commit crimes, often because they have no real choice. 

We have differential standards for defining and responding to crimes that have been committed by the affluent and the elite, and crimes that have been committed by the poor and the marginalised.

We punish certain types of crime committed by certain types of people more harshly which is evidenced by the fact that we imprison poor and brown skinned people more often, and for longer than we do affluent or white people. 

Our incarceration rate of poor and brown skinned people, like the incidence of poverty-related child abuse, is a national disgrace and makes a mockery of New Zealand's claims to be the progressive, first world nation it likes to think it is. 

Māori are 14.6% of New Zealand's population and 51% of its prison population.  At current incarceration rates, Māori will half fill the hugely expensive new prisons the National Government is committed to building.

This ugly reality and the pretence that we are a decent, egalitarian and just society creates massive cognitive dissonance. Many Kiwis deal with that by excluding those people from the 'real' New Zealand; they label them as 'feral', as undeserving, as pathological. Their existence is deemed to be an aberration, nothing to do with real Kiwis who are fundamentally egalitarian, hardworking, decent and just. 

We pat ourselves on the back for such things as being progressive towards the LGBT community, for  having partly closed the gender wage gap, for being the first country to give women the vote, for having a young woman and a Māori man in the running to become Prime Minister and Deputy PM.  

These are all very laudable things but frankly,  while we have families that are forced to live in cars, homeless people who die of cold on the streets, 300,000 kids who live in poverty, an appalling rate of violence against women and children, high levels of horizontal violence and incarceration of men of colour at rates which match those of the most racist of American states - we have no right to be smug and self congratulatory.  

I will leave you with this thought: if Black and Hispanic Americans were incarcerated at the same rates as White Americans, the US prison population would drop by almost 40%.  

If Māori and Pacifica men were incarcerated at the same rate as White New Zealanders, we would not need 1800 new prison beds and we could be looking at better, more social and productive ways of spending 1 billion dollars. 

Tuesday, 29 August 2017

In Place of Fear

This election gets more and more interesting.  

Last Sunday, Winston Peters, leader of New Zealand First, revealed that he'd been overpaid on his superannuation. It appears that the Ministry of Social Development's calculation of his superannuation had been based on the single person's rate. As Peters is in a de facto relationship he should have received a lower rate.  The overpayment came to light when his partner applied for superannuation.  Peters sorted it out and immediately repaid the sum owing. He says he has no idea how incorrect information came to be on his records given he went through the paper forms with a senior MSD official, and his partner was present.  

Maybe there was a data inputting error but, as has been argued by National’s pollster, David Farrar, Peters should have received regular letters asking if the information on file is correct, which should have alerted him to the problem.

All I can say about that is, neither my husband nor I can recall ever receiving such a letter from the MSD. 

Peters will not waive his right to privacy to allow the MSD to comment, and why should he? His privacy rights have already been breached by the leaking of information from either the Inland Revenue Department (IRD), which administers the superannuation payments, or the MSD or, as is now emerging as a distinct possibility, the Beehive.

By going public on Sunday, Peters pre-empted the story that had been touted by Newsroom as the 'mother of all scandals' (MOAS) which was going to break on Monday. 
The co-writer of the story, Tim Murphy, former editor-in-chief of The Herald and co-editor of Newsroom, later claimed on Twitter that the MOAS claim had been 'hyperbole' to wind up Newshub's Political Editor, Patrick Gower.  

If that was true, Newsroom was about to reveal something that could end a political career and change the face of an election, yet its co-editor thought it was a good idea to wind up another journalist and set the Twittersphere on fire.

It may well turn out that the MOAS is not the Peters' overpayment and what caused it, but the use of private information in another dirty politics campaign in the lead up to an election.  If that proves to be the case, senior staff at Newsroom were either actively complicit in it, or were used as tools.  Either scenario brings their professionalism and political acumen into question and has caused some serious cracks to appear in Newsroom's glossy veneer. 

What it says about the National Party and its involvement in dirty tricks in the lead up to another election has yet to be made clear.  

What we know is that the overpayment was referred to Anne Tolley, Minister for Social Development, under the 'no surprises' rule on July 31st and again August 15th. It was passed onto the Prime Minister's Chief of Staff who says he decided not to tell the PM.  It was also revealed to the Deputy Prime Minster, Paula Bennett, who used to be the Minister for Social Development and who has been under public scrutiny for alleged breaches of MSD rules in the past; and - somehow - it was leaked to the media and went public just 3 weeks out from an election in which the subject of the leak is very likely to be a key player.

I can't understand why Peters - as a party leader, a wealthy man, a lawyer, the champion of superannuitants, a wily and very high-profile politico whose de facto relationship is well-known - would have claimed to be single on his superannuation application.  And why would he ignore letters asking him if the information on the system was correct? 

I'm not saying it's impossible, just that it seems highly improbable. 

Unlike poor superannuitants, for whom every dollar they get matters in real and pressing ways, Peters has no need to count every dollar he gets on his super and I can well believe that he simply had it paid into a savings account without stopping to think about the actual sum, and that he leaves all of his financial stuff to his accountant.  I bet he's not alone in that.
So, was this a dirty politics strategy to use the information to destroy Peters' credibility and, with the Green vote in disarray, push blue-green and NZ First voters to National to allow it govern alone with the increasingly noisome David Seymour of ACT?  

It certainly looks like it. 

And of course, there's the added bonus of softening up the public for future changes to universal superannuation - such as introducing means testing or even phasing it out completely.  After all, the rich don't need it, the affluent can manage without it, and the poor can continue to subsist on welfare benefits - or die. 

As to the claim that Peters would have known precisely what he was due, my husband and I didn't.  We assumed the people who processed our applications were competent and would understand and fairly apply their own rules.  It was only when we encountered the retributive and potentially punitive nature of the system that we felt the need to do our own research.  

What I had thought would be a simple process of lodging a claim for NZ superannuation became embarrassing and anxiety inducing when, in an open-plan office, with no attempt to ensure privacy, I was told that my husband had been overpaid because he had not updated information about my income. The member of staff said that there would be an investigation; that it would be a significant sum; that there could be penalties, and that a prosecution was 'unlikely unless it was deemed to be a deliberate fraud'. 

It was shocking and it left me feeling highly stressed. It was also wrong. There had been no overpayment. Either the information on the computer did not match that on the original paper form and this was subsequently established and corrected, or the employee was wrong in her understanding of the rules.  We suspect the latter but we don't know because we never got a formal explanation, let alone an apology. 

We thought about lodging a complaint but frankly at the time I wanted nothing more to do with the organisation. I left there feeling deeply grateful that I do not have to deal with it on a regular basis.

Our experience with the MSD was a relatively insignificant episode but it was symptomatic of most NZ bureaucracies and especially so of the MSD which, at times according to my husband, could more properly be called the Ministry of Social Destruction.  

This sort of institutional culture :

works on a deficit model of human behaviour which makes employees assume the worst about people and encourages them to look for ways that can be confirmed;

is regulatory rather than facilitative i.e. the primary function is to apply rules in ways that erect, rather than remove, barriers;

is austere in that it encourages employees to depersonalise, and actively discourages them from empathising with their 'clients;

is moralistic in that clients are often informally labelled as either deserving or undeserving; and, 

is parsimonious in that it encourages its employees to see themselves as the guardians of the public purse which is always at risk of being pilfered by the undeserving.

All of this rests on the individualisation of the social contract - summed up in the vacuous Thatcherite notion that there is no society, that there are only families and individuals who are largely responsible for themselves. If they fail it is because of their own shortcomings; if they succeed it is because of their own merits.  

The current welfare system in many ways harks back to the ethos of the Workhouse which split families by forcing men and women to live separately and which made the conditions of relief so harsh, so degrading and so cruel that any sort of work, at any sort of wages and in any sort of conditions was preferable to it.  It is no accident that the Poor Law Commissioners and the Workhouse loom so large in British history and why they were so detested. 

Of course the welfare system today is not as crudely moralistic or as cruelly and overtly oppressive but it springs from the same rootstock.  A class of smugly content haves imposes forms of regulation and retribution on a class of increasingly discontented and desperate have-nots. 

I felt uneasy about criticising the MSD because of its punitive culture and the enormous power the state wields courtesy of the knowledge it has about almost every tiny detail of our lives. Imagine how it is for people who are utterly dependent on the state for their subsistence.

One of the worst things about the Peters' scenario and what happened to Metiria Turei, is the message it sends out which is that big brother really is watching you, and if he decides he needs to, or simply wants to, he can give you the father of all kickings.  

There's an important principle here. NZ is split end to end and if we don't heal the wound it will finally kill what's left of our culture of decency and a fair go.