March 26, 2012
New Families

H.G. returned to Frankfurt to look after his parents in their old age. When he returned, he was reunited with an old friend, a man twenty years older, a successful textile designer, Horst. Horst was born in Koenigsberg, East Prussia, an ancient outpost of the German empire (it was founded by the Teutonic Knights in 1255), until the Second World War, when it became Russian. It is geographically isolated from the mainland of Russia, lying between Poland and Russia. It was heavily bombed during the Second World War and in 1945 it was invaded by the then Soviet Union, which forced out the remaining German population. The philosopher Emmanuel Kant was born there.

Horst was an orphan of the war, who was raised by a German woman who left Koenigsberg and brought him to West Germany. Despite his lack of advantages, Horst succeeded in becoming a highly paid luxury textile designer, living a splendid life. Generous, he was surrounded by friends whom he loved to entertain, laying on silver, crystal and porcelain on a groaning table set for merry holiday parties.

In his sixties he faced retirement without having saved for it, and his fortunes slipped, although his friends stood by him. He had no family save his friends. He was a mentor to the son of one of them, a woman who had lost her husband. In all things he was a loyal gentleman, and the change in his financial situation did not alter that fact.

In his seventieth year he lost his voice: he was a smoker, and so it was not surprising that he was diagnosed with lung cancer, which was in the fourth stage. He had ceased to contribute to the health insurance system some years before, as Germany's health system did not adjust for the fall in his income. So when he became ill, he could not be accepted as a patient by any doctor accepting health insurance. H.G. took him to a doctor and paid him cash for the visit and arranged for Horst to be re-entered in the health insurance rolls. This required payment of all the moneys not paid into the system during the years Horst did not contribute. Horst was admitted back into the system just when he was diagnosed with lung cancer.

H.G. was simultaneously working for the electrical company and acting as Horst's care manager, filling out forms, making the phone calls, going with Horst to his appointments for chemotherapy. Horst wanted every possible treatment that might help him live longer, but at one point the doctors told him that there were no more options for treatment that would significantly prolong his life. He could continue to receive chemotherapy in the hospital, although it would be of limited duration: he could go home and come to the hospital for chemotherapy, or he could go into hospice. Ultimately, he decided to go to hospice, where he died peacefully at the end of February 2012.

In the German system everyone has health insurance, but there is a public and a private health care system. Government health care involves the primary care doctor acting as gatekeeper for specialist care: the wait for an appointment takes several weeks. Patients paying privately for care are seen immediately. Those on government health care have paid as little as ten Euros every month as their contribution, although at one point the government required that individuals pay a ten Euro co-payment per visit, a measure that provoked street protests. The measure was eventually revoked.

Nevertheless, the model of universal health care is sagging under the weight of its structure. Despite public outrage, the social safety net will be stretched, and health care will cost more. While in Italy and Austria I saw many smokers; there were fewer in Germany, except among non-ethnic German groups, like immigrants from Turkey, "where smoking is a national duty", as a Turkish man said to me once. The terrible fact is that in the modern era individuals must contemplate the likely probability that they will meet with a terminal illness the treatment for which is necessarily tiered by economic factors. While better treatments may be available for many cancers, they will be too expensive to be made widely available by government-sponsored health plans.

The paradox is that before the Second World War there was little that could be done about cancer, except to accept its death sentence. Family members had responsibility for palliating the suffering of the sick individual with more or less help from a local physician. Today, with extended family life attenuated by geographic factors, and even the nuclear family less viable, more and more people will not have family members to count on in their last days. The problem of giving compassionate care to the dying is one the social safety net provided by the government does not contemplate. It therefore becomes more incumbent on individuals unrelated by consanguinity to develop the networks to care for each other, one by one, even as the old structure perdure.

H.G. has been changed by his experience of caring for Horst. He worked previously in the "gift industry", which as the European economy slows, is no longer as lucrative. However he could return to it, or find work at a large financial services firm, which abound in Frankfurt. He considers his future, (he will be fifty in August 2012), and his feeling of obligation to his parents and their need for a caregiver nearby. Ultimately, he wonders whether it would not be best for him to take his administrative skills and utilize them providing care for people, including his parents, who are overwhelmed by the tasks involved in making the health care system work for them, replicating what he did for Horst voluntarily as a means of making some money, but also doing good.

The middle-man between the health care system and the individual is emerging as a necessary factor in the provision of health care. The loving care of one individual for another will never be replaced by a middle-man, but without a middle-man, the sick individual risks being victimized not just by his illness, but by a modern health care system whose crucial details only those who work regularly in it grasp.

New families are created by these networks of patients, caregivers, care managers and caretakers. The individual extended family will be a rare survivor of the traditional social grouping. Simultaneously, even the nuclear family is being replaced by the re-constituted family, as individuals dissolve their marriages and enter into other relationships, with or without new children, and with or without marriage licenses or civil partnership certificates. As individuals age, more and more individuals will create "ad hoc" structures that are constructively families, although the actual connection is one of sympathy, not bloodline.

Which leads to the question: "How are individuals to pursue their destinies most happily under such circumstances?" The answer can only be through the strong social relationships that are legally informal but that replace the traditional extended or nuclear family most of us grew up with. Europe and the United States face the same problem, although "Old Europe" (as George W. Bush's Secretary of Defense, Donald Rumsfeld once referred to the continent) is talking about it openly, unencumbered by the "focus on the family" that is a lightning rod for our own political debates, characterized as they are by a high degree of intolerance of differing views.