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Palerider's avatar

This in no way detracts from the value and existential necessity of works such as Lelievre's. However.

No amount of analysis and insight will solve anything without action.

Action does not require majority support or validation. Societal change is achieved by committed (often very small) minorities. We are surrounded by living examples.

Gary Weglarz's avatar

As a long retired clinical social worker I have many experiences from my time working within large institutional structures that flashed before my conscious memory while reading this fine essay. One memory in particular came to mind, perhaps because of the sense of Orwellian disequilibrium it created at the time. While working for a very small rural Alaska hospice program we (our team) were being "surveyed" by an accrediting agency in order to maintain our certification to receive the Medicare funding that pays for most hospice care. Our tiny program was staffed by literally a handful of people, all of us wearing multiple "hats" for the various "roles" we played in providing service. I will never forget the smiling, congenial attitude exhibited by the surveying team from somewhere in the lower 48 states as they explained all of the "improvements" to our services and service provisions that they were officially recommending in their report in order for us to remain "accredited" and able to bill Medicare. Forget the fact that as a tiny program with very little in the way of staff or financial resources we had absolutely no way on earth to meet these "new requirements" that supposedly were the latest in new measures of the "quality" of the services we provided. Also keep in mind that I had already worked in three different much larger hospice programs in the lower 48 states - large programs that could not hope to match the actual - "quality of care provision" - that our small program provided our local community, but that with much larger budgets and staffing allotments could more easily "jump through the hoops" of these new "standards" and "protocols."

I will always remember the Orwellian, truly almost Kafkaesque scene as our tiny team sat down for the exit interview with the team of surveyors and they explained to us all of things we would now "need to do" in order to be "approved" - most of which we had already told them we could not possibly comply with given the small size and limited resources of our program. I remember how their smiling faces and upbeat demeanor in that meeting completely clashed with the "reality" of the situation as myself and the rest of our team experienced it. It was if while torturing Winston, Big Brother was kind, upbeat and congenial as he was asking the traumatized Winston - "how many fingers am I holding up?" The disconnect was stunning. A group of well meaning, organizationally rigid, "by the book" functionaries from a large institutional structure that was used to surveying large hospice programs in the lower 48 states - simply seemed to have no idea how to in anyway accommodate the very different on the ground reality's faced by a very successful and important, but very tiny hospice program in rural Alaska. The surreal nature of that scene has always stayed with me. Along with the realization that large ossified institutional structures can act in ways completely counter to their stated "goals" (i.e. - improved patient care) - and not only not miss a beat - but also manage to seemingly filter out all important information they might have difficulty incorporating institutionally. No malice, no harm intended. "Just following orders" - as it were. : /

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