What Money Cannot Buy

How to put tender loving care back into nursingthat is the problem examined here by the Dutch novelist Jan de Hartog, who catalogued many of the critical limitations of modern medical care in his 1964 best seller, THE HOSPITAL.Mr. De Hartog is the author of several novels and plays and spent nearly four years as a volunteer orderly in Houston’s City County Hospital.

by Jan de Hartog

ONE stormy night in the fall of 1964, around eleven o’clock, I was called to the telephone at the nurses’ desk in the emergency room of Houston’s City County Hospital, where I worked as a volunteer orderly. The emergency room of the charity hospital was the only one that operated on a twenty-four-hour basis in the city of Houston; it was frantically busy most of the time; on nights like this it was a madhouse. As I hurried to the desk, I wondered who could be telephoning me here, at this hour. It couldn’t be my wife, who worked in Female Medicine upstairs the same shift as I, for we had agreed that I would come to fetch her whenever I was through.

It turned out to be a reporter from one of the Houston papers. His specialty was local politics; in the past I had often benefited from his intimate knowledge of the personalities and motivations of the local politicians. My wife and I had arrived in Houston in September, 1962, and had become involved with the city-county charity hospital a few weeks after that. Conditions as we found them were such that we felt compelled to inform our local Quaker meeting and ask for their help; thirteen members agreed to take the Red Cross training course and pledged to serve in the hospital one day a week once they had received their license.

Our small group had worked in the hospital for nine months when a city councillor suggested that the budget of the hospital be cut. This resulted in such despondency among the already inadequate staff that our Quaker meeting decided one of us should write an article for the papers, to inform the citizens of Houston. As a professional writer, I was the logical choice. I wrote the article, which turned out to be the first innocent step toward a much deeper involvement: a book on the hospital to rouse the community into action. The night of that secretive telephone call, the first chapter of the book was about to be published as a pullout section of the Sunday Houston Chronicle.

My caller, sounding more and more like an actor in a spy movie, urged me to meet him as soon as possible after my shift, for be had something of the greatest importance to tell me. I warned him that this might not be until two or three in the morning; the emergency room was turning into bedlam; four ambulance stretchers with moaning or unconscious victims of accidents or violence were lined up at the desk waiting for the first cursory examination, after which the patient could be transferred to a hospital stretcher.

“Let’s meet at Louie’s,” the voice in the telephone said. “I’ll be there at one o’clock. Try to make sure that no one sees you. This is serious.” Then he was gone.

Louie’s is an all-night diner on the outskirts of the city, frequented by truck drivers. When my wife and I finally arrived toward three in the morning, the parking lot was jammed with giant trailers. Inside, a jukebox was booming a watusi tune with convention-hall volume. Our friend sat hidden in the farthest booth: “Ah! At last! I thought you’d never come.”

“I’m sorry,” I said. “You shouldn’t have waited; we couldn’t make it any earlier. What’s up?”

I must withdraw my book from the market, he said, or at least postpone its publication date; under no circumstances should that first chapter be published in Sunday’s paper, or I would be rubbed out like a bug. Houston, he said, now the number one boomtown in the United States, was a city without leaders. The old ruling clique of local millionaires who had run the city as a private hobby from their club and their downtown offices had gone; no new group or combination had taken their place, so here was the richest political plum in the Southwest, ripe to be picked by whatever machine or Mafia got there first. At this very moment, two powerful groups from up north were competing for control of the city. It was a toss-up which one of them would win, but as far as we were concerned, the outcome did not matter. What mattered was that neither combine was likely to tolerate the emotional commotion the book on the hospital was sure to cause, and he felt he had to warn me, most urgently. It sounded utterly fantastic to me, but I could not doubt his sincerity, and the urgency of his concern was underscored by the fact that he had been sitting there since one o’clock.

“But why?” my wife asked incredulously. “Why should anyone consider him a political opponent, when all he’s doing is telling people what is going on in the charity hospital? It’s a purely humanitarian issue —”

He looked at her before he answered. He seemed to take in her nurse’s uniform, her kind dark eyes. her tired face radiating the compassion common to those who battle in vain with the suffering and death of others. It seemed as if during that moment of silence she embodied for him a hope that he knew would never materialize. Then he said, “ The only time a political machine can take over a community is when its people don’t care what happens to anybody else except their own families. So, to the manipulators who are planning a take-over, anybody who arouses in people a concern about their neighbors is a threat. It doesn’t matter what the concern is about, a charity hospital, the poor, the Negro; the moment people are shaken into awareness of what’s going on around them, the combine that wants to grab control has lost its chance. The boys in question know this as well as I do. After fifteen years in this business, I have passed the stage where I thought of humanity as a pack of hyenas. I have come out the other end, and know by now that in every man, however cynical and selfish he may seem, there is a secret yearning to respond to a movement of pure goodness. It is a latent atomic power that when unleashed will wipe out any political machine that operates on the basis of contempt for humanity. The boys in the back room, if they are not just a bunch of local hicks out for chicken feed, but big leaguers, recognize a potential rabble-rouser when they see one. And believe me, they don’t mess around when they do. My guess is that once you publish that excerpt in the paper, they’ll — ” He snapped his fingers, and smiled.

I HAVE related this incident because it sums up a basic conflict in our modern urban society and contains the seed of its solution. As it happened, Houston was not taken over by a political machine, but I cannot judge how real the danger was when our friend communicated his dramatic warning. The book was published on schedule, and the pullout section containing its first chapter came out in the following Sunday’s paper as planned. No one tried to rub us out or made a move that could even remotely be interpreted as violent.

The reaction of the citizens of Houston was unequivocal and, at first sight, bizarre. To the appeal for money for the hospital they failed to respond, as had been their consistent custom for the past fifty years, but the reaction of what my friend had called their “secret yearning to respond to a movement of pure goodness” was staggering. One instance will illustrate this. The actors of the Alley Theater, Houston’s leading professional company, organized, within a day of the publication of the chapter in the Houston Chronicle, a benefit performance for the charity hospital. Anyone who fancied seeing the first play of the season before anyone else, who liked to see his name in the paper, and who cared to contribute to a worthy cause could have all three for the modest price of ten dollars, deductible. To the dismay of everyone connected with the benefit, less than one hundred people turned up; the theater was obliged to paper the house with nurses and students.

But during the same period of time, over four hundred citizens enrolled for training as volunteer orderlies and nurse’s aides, pledging themselves to serve a minimum of four hours per week thereafter. To put it more graphically, while less than a hundred people were prepared to part with ten dollars for the sake of sick old nigras in Ben Taub General, four hundred were prepared to carry their bedpans. Since September, 1962, when we started with three, over six hundred volunteer nurse’s aides and orderlies have been trained. One need only ask the administrator and the director of nurses to find that these volunteers—if they arc directed and supervised by the nursing office and not some outside agency — completely identify with the hospital, are highly reliable and totally dedicated to the care of their patients.

In the November, 1965, election, the Houston charity hospitals were at last voted sufficient funds to operate as hospitals instead of public utilities to keep the dead and the dying off the streets; so the financial emergency is past. But the element that money cannot buy — the personal concern, the respect for the human dignity of the individual patient, which had virtually disappeared after fifty years of public indifference and neglect — returned with the arrival of the nursing volunteers. It was not just the fact that these people were highly motivated and emotionally mature; their secret was (and is) that they work in the wards only one shift each week, and thus are able to carry into the hospital the kindness and the concern they would show for a member of their own family who had fallen ill.

For to deal with the sick in a professional capacity during a forty-hour week inevitably results in a detachment that often, unobtrusively, deteriorates into indifference. Even the most luxurious and richly endowed hospital, if it happens to be a teaching hospital connected with a university, runs the danger of falling victim to the depersonalization of the patient. Dr.

John H. Knowles, M.D., general director of Massachusetts General Hospital, stated in an address to the Association of American Medical Colleges in Miami on December 9, 1964: “In instances where teaching and research have dominated the hospital, the attitude has become set that the patient exists for the teaching program and not that the hospital exists for the patient.”

Since my service in Houston’s charity hospitals, I have come to know many other hospitals in the United States as well as abroad. I have found that the majority of these show the symptoms described by Dr. Knowles, which can be assembled under the heading “the efficiency syndrome.” I have come across very few hospitals where efficiency has not become the ultimate consideration by which “success” is measured. At first sight, this passion for efficiency would seem beneficial to the patient; in practice it does not work out that way. Efficiency demands rules and regulations; rules and regulations are by their very nature impersonal, concerned as they are not with people of flesh and blood in pain and fear, but with “the patient,” a purely administrative unit to be fed into a computer. In addition to the shortage of professional staff being experienced in most hospitals all over the world, we are faced with the acceptance of the computer as the ultimate arbiter between good and evil. This combination will inevitably result in the death of compassion, and occasionally, in the type of insanity to which computers arc congenitally prone. A story now going the rounds of academia tells of a Dutch professor who demonstrated this insanity by feeding into his country’s most sophisticated computer the following question: “I have the choice between two watches, one is broken and irrevocably stopped, the other loses one second per 24 hours. Which watch should I use?” The computer replied, “The one that is stopped, as it indicates the correct time twice every 24 hours; the other one does so only once every 120 years.”

This kind of logic will ultimately prevail in any hospital where efficiency has been proclaimed the standard by which all else is measured. Anyone with some knowledge of modern hospitals, either as a worker or as a patient, will be able to furnish examples of this. Typical is one concerning a young father who wanted to take his wife and newborn baby home and who found himself without his checkbook at the cashier’s desk. He was told by the clerk on duty that the hospital would not release the baby until the bill was paid. The hospital in question was one of the most famous and expensive private hospitals in the Southwest. I cite this example because of its comparatively innocuous nuttiness; I could cite others of steadily diminishing innocence, down to instances of bureaucratic savagery perpetrated under the pressure of “having to obey the rules.”

Unless we do something and by “we" I mean you and I, citizens of our modern urban societies — the process of depersonalization of “the patient” is bound to reach a point where it begins to attack the very humanity of our communities. When all is said and done, the element that ultimately determines the difference between a human community and a society of insects is communal compassion, Ever since the dawn of civilization, the concern for the sick and the injured has been considered the one closest to the Divine among all man’s preoccupations. Not only in Judaeo-Christian ethics but in most religions of mankind, a variation can be found of the basic tenet of the New Testament: “Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.”Today, “the least of these” rarely appeal in vain to the charitable impulses of their more fortunate brethren. In the highly intricate, multileveled complex of the modern hospital, there can be found, as a rule, a charity ward or privately endowed beds for indigent patients. It is not the least of these, but their more fortunate brethren who seem to be lost souls in the hospitals of today, vainly waiting for a look of recognition, a smile of understanding, the comforting hand of a neighbor who recognizes in them the indwelling presence of the Divine. Who among my fellow hospital workers has not at one time or another witnessed the loneliness of the firstclass patient? There he lies, in his motorized bed, which will elevate head, knees, or feet at the touch of a button. Surrounded by gadgetry. staring disconsolately at a television set, he is addressed via a loudspeaker by the impersonal voice of the nurse on duty. In response to his call she replies, efficiently: “Yes?” Imagine her reaction if the loudspeaker on her desk were to answer, “Love me.”Yet this is what each call amounts to, though the actual words may be, “I’d like a glass of water, please,” or “My feet are cold, may I have a hot water bottle?” or “Could you give me something for my pain?”

All experts agree that with the advent of Medicare, the building programs, and the chronic shortage of nurses, a situation will soon develop where virtually every hospital is critically understaffed. The experts’ answer to this imminent dilemma is “increased efficiency,” or “more automation,” or a combination of the two. The generally accepted aim is to reduce the number of professional staff per patient.

It is my conviction, based on practical experience, that this solution will compound the problem. The problem is not so much the lack of professional staff as the decline in TLC, “Tender Loving Care,” the gradual shift of the concept of nursing front a calling to a profession like any other. There was a time when, once they ended up in a hospital, the sick were certain to find an atmosphere of kindness and motherly concern. The nurse who modeled herself after the example of Florence Nightingale, or in Roman Catholic hospitals the nursing nun who was religiously rather than economically or socially motivated, had an attitude toward her patients that was intensely personal. I have known, as a boy, hospitals where “matrons,”as they were then called, reprimanded sisters because they talked about “they” when referring to patients. I remember one intimidating director of nurses, with rimless glasses, rustling skirts, long-distance boots, and the faint lavender smell of an oldfashioned linen cupboard, who sternly berated a young nurse because she had dared to say, “They always try to get out of bed, saying they want to go home.” referring to people who were about to die. “Only God,” the matron said, her voice quivering with dignified outrage, “may have cause to refer to suffering human beings in the plural, although I doubt whether He does. You, miss, by generalizing about your patients, are denying the very essence of our calling. In future, before you go in for a sweeping statement, substitute ‘my mother’ for ‘they.’ ” I have often thought of that matron, and how horrified she would be today to find a newly arrived patient sitting disconsolately on the edge of her bed, welcomed by an immature, unimaginative aide with a list, ticking off new arrivals.

“Your name, please.”

“Doe. Mrs. John Doe.”

“Any pain?”

“No . . .”

“What are you here for?”

“I — I had a miscarriage . . .”

“D and C. OK. Undress please, and get into bed. There’s your bathroom; here’s your ice water; this controls the position of your bed; this, the TV set; you’ll find the speaker under your pillow. Anything you want, press this button and wait until the nurse at the desk answers you; then speak clearly into this mike. OK? Bye now.”

There she lies, the young mother who has seen her hopes dashed, whose dreams have suddenly turned into emptiness and despair. If ever there was a creature in need of tender loving care, it is she, but because she came into the hospital on foot instead of on a stretcher, the young aide entrusted with the care of her bruised humanity ticks her off on the list as NH, ”No Hurry.”

The old matron who used that outdated and by now corny word “calling” would have been horrified at other things, too. In her days, no hospital worthy of its name would have put a patient admitted for a D and C after a miscarriage in Labor and Delivery, where every sound, every sight, spells babies being born. Fathers are pacing, mothers-to-be chat in the doorways of their rooms, heavy with child. No one stops to recognize the cruelty of taking the young mother who lost her baby past shops with baby clothes and toys, waiting rooms full of chain-smoking males and a sign over the door showing a bird carrying a bundle and the words “Stork Club.” The efficiency in dealing with human parturition has increased a hundredfold since the days of the buxom busybody who fussed so bossily around the high railless bed; but the very essence of her calling has been lost in the process.

How to put tender loving care back into nursing? This, it seems to me, is the crucial question facing our urban hospitals today. Not just in the United States, but everywhere in the world, in every growing megalopolis, the same specter of dehumanizing efficiency roams the aseptic halls of the institutions of healing. There is more at stake than pandering to the sensitivities of a few highly strung or anxious patients; every patient entering a hospital is highly strung and anxious, only some hide it better than others.

Somebody, somewhere, will soon have to step in, and by sheer power of identification, liberate the hospital patient of today from the traumatic realization that all he is — with his pains, his fears, his unique and immortal soul — is a cog in a machine that is obsessed by the esoteric intricacies of its own operation. The only effective solution I have seen is the admission into the closed shop of the hospital of mature, specially trained, and professionally supervised nursing volunteers. Not the ladies in pink, blue, gray, or yellow who man the information desks, the gift-shop counters, and the cafeterias, but fully trained, licensed orderlies and nurse’s aides, drawn from the community, who will work one shift a week as a civic service.

The United States is full of mature middle-aged men who would like to plow back some of the harvest of their lives into the common field. There are millions of mature, experienced women yearning to put to use all the warmth, the common sense, and the capacity of identification that result from the raising of a brood of children. The children have gone, time is on their hands; who wants the wealth of tenderness, concern, and understanding of those millions of mothers-on-the-dole, now bleakly facing the bridge table, the seminar on seventeenth-century painting, or the Caribbean cruise? Hospital administrations and boards of managers, medical directors and directors of nurses who exclude this tremendous potential of tender loving care for reasons of pride, prejudice, or prestige do so to the peril not only of their patients but of the community of which their hospital, for better or for worse, is the soul.

And here we return to my friend the political journalist and his warning that night in the diner. His “latent atomic power” is not a romantic fancy; it is a reality that I know, for I have seen it.

I have seen it take hold of one of the worst hospitals I knew and shake it to the marrow and transform it by the indomitable dedication of a handful of nursing volunteers, dedication to the dignity of the individual patient, to the uniqueness of the human personality, to “that of God in every man.” No overworked R.N., no harassed aide, no virile young intern, no administrator distracted by dreams of efficiency can ignore for long the mysterious presence that moves into any hospital once it admits these mature, well-trained, and highly motivated nursing volunteers drawn from their own community. It is not the idea that they replace professional staff; they are meant to supplement it. They do not encroach upon the duties of the nurse; they release her for the jobs she is qualified to do. All they will do, and do supremely well, is to perform that totally inefficient and administratively intolerably wasteful task known as “fussing around the patient.” I see no hope for either the hospital, the community, or the patient unless the impulse of mercy, hibernating in each of us, is allowed to reach out to those who need it, and who will need it more desperately with each passing day.

Let the churches organize groups of volunteers among their congregations, let the Red Cross or the instructors of the local health department train them in evening or daytime classes until they are qualified to work as orderlies and nursing aides. Then let them take care of the basic physical needs of “the patient,” under the supervision of hospital-appointed professional supervisors and under the direction of a hospital-salaried, full-time director of nursing volunteers.

The result will be the breaking of the vicious circle, the end of the dehumanization that is bound to increase with every increase in efficiency.