Un-demonising the marginalised

In The Time Machine by HG Wells, a ‘gentleman scientist’ travels into the far future and finds that humanity has evolved into two distinct species; The Eloi are innocent, docile, and largely idle, and are preyed upon by the Morlocks, feral monsters who live underground. As Wells describes it, ‘Ages ago, thousands of generations ago, man had thrust his brother man out of the ease and the sunshine. And now that brother was coming back changed! Already the Eloi had begun to learn one old lesson anew. They were becoming reacquainted with Fear.’ ¹

This month’s theme is ‘marginalised people’. The very word ‘marginalised’ conjures a sense of us and them, and a space that we inhabit. At the boundary of our space and the outside lies the ‘margin’. Some people end up at this border and others are excluded. Those inside who enjoy the (relative) ease and sunshine risk unjustly marginalising even excluding others. O’Carroll’s essay points out that many of those who we label as having personality disorders may be so because of poverty and adverse childhood experience. By labelling people as vicious or faulty rather than damaged we render them ineligible for help and sympathy while exculpating our society from mitigating and preventing lasting psychological harm.²

We fear the marginalised patient because they might invade our ease and sunshine. Many a clinic has run late because such a person’s needs or ability to engage with services do not fit into half an hour, much less 10 minutes, and such frustration in a system under pressure can lead to less charitable thoughts and feelings. Populist politicians can make Morlocks of those who can easily be ‘othered’. Monahan, in reflecting on an elective in homeless medicine, takes this idea further, and challenges us to consider that our place in the ease and sunshine is in large part an accident of birth: where we were born, who raised us, and the opportunities we have been given.³

Churchill reminds us that an entire generation of young people were disaffected and disadvantaged in terms of their health and access to health care even before the pandemic made things worse.⁴ Access and continuity loom large in the 10 most read articles in last year’s BJGP.⁵ The link between continuity of care, health outcomes, and survival was astutely picked up by the chair of the UK Health Select Committee, The Rt Hon Jeremy Hunt MP. I hope he recognised that making the barriers to access the responsibility of a named GP does not of itself solve a problem that includes chronic underinvestment, workforce depletion, and social factors that make continuity difficult to sustain. Being ‘named’, at worst, is only a way to be ‘blamed’.

Andrew Papanikitas

When considering medicine and even life at the margins we often focus on the people rather than the effect that the bubble we inhabit can have on us. Kemple reminds us that we have to look outside our bubble of comfort, home, and work because what happens outside will affect us. In fact, our short-term interests in maintaining our position of ease and sunshine may prevent or even be used by the mischievous and misguided in preventing us from doing what is right globally or in the long term. This article⁶ is the first of a BJGP Life column entitled Planetary Primary Care — submissions are welcome via www.bjgplife.com.

Can GPs and other healthcare professionals themselves become marginalised? Zigmond discusses ‘… the insidious and cumulative demoralisation and depersonalisation of healthcarers who have lost a sense of vocational pride and satisfaction, and collegial trust and belonging in their work.’ ⁷ Some of these trends require political activism and local leadership, but there are also ways we can help ourselves and each other at the grassroots. Aird challenges us to look outwards, up and forward in a set of hopeful reflections on the new normal in pandemic times.⁸ Have you been inspired or challenged by a book you have read recently? Do consider whether a book review on BJGP Life might help others. Recently released books and relevant classics in any genre will be considered. Have a look at the reviews in this issue and on the BJGP Life pages.

While primary care in these times is rarely characterised in terms of ‘ease and sunshine’, the articles in this issue offer some approaches to un-demonising the marginalised, whether they are them or us.

• © British Journal of General Practice 2022