Watching you wear out: Time as clinical labor

Abstract

Drawing on clinical fieldwork in NHS general practice in East London, I consider the relationship between time, chronic illness, and therapeutic endeavor. Over the course of three treatment narratives, I attempt to show the negative labor that I claim is implied when clinical time is used to watch and wait as somebody is “wearing out” from chronic conditions. This may be the only form of care available to clinicians in situations where medicine is limited in what it can do to intervene. It emerges in response to illnesses that must be allowed to run their course and recurring symptoms that must somehow be tolerated, tarried with, or “waited out.” The aim of the paper is to try to engage the grey area between medical intervention and non‐intervention, where time in the clinic is offered in the service of helping people to wear out on their own terms.

INTRODUCTION

ʻʻYou see my brain was no longer able to bear the pain and

anxiety with which it had been burdened. It said: ‘I'm giving up;

but if anyone else here cares about keeping the whole intact,

then he should share the load and things will run a little longer.ʼʼ

Franz Kafka to Milena Jesenska¹

Reparative forms of care are not always available in situations where medicine is limited in what it can do. Yet the ongoing work of responding to intractable health problems is rarely accounted for. This article is set against the backdrop of a three‐year study of a General Practice in England. It examines care in relation to complex and chronic long‐term health conditions. In contrast to representations of healthcare as active, targeted, and timely, the article features ethnographically derived accounts of NHS general practitioners responding to unstoppable psycho‐social and physical decline and deterioration. By tracking the negative labor of not being able to reverse or alleviate a deteriorating condition or slow down its progression, I center clinical work in relation to chronic, “complex” conditions. My claim is that it often includes some form of watching and waiting whilst a patient's resources for enduring and overcoming slowly “wear out.”

Since its inception, when it was used mainly to describe certain age‐related illnesses, the chronic illness has eclipsed all other types of illness. In 2015, the Global Burden of Disease Study found that only four percent of the earth's human population was not suffering from some form of sickness, a surreal finding that the researchers traced back to longer life expectancy leading to chronic disease becoming more typical of the ageing experience overall (Vos et al, 2015). Whilst more diagnoses of chronic disease worldwide may be helping to address one type of health crisis, the therapies needed to manage these long‐term conditions do not always exist and when they do, they are not always available. One of the contradictions of the global drive to diagnose more chronic conditions, is that it opens up another type of health crisis characterized by the inability to ever come to terms with the idea of not getting better. Locked in a state of protracted expectation, the chronically ill subject can be caught between the imperative of taking the steps needed to improve the quality of their life and the imperative to do whatever is necessary to get through the day. As Cinzia Greco and Nils Graber point out in their special issue on the subject, cases of the “new chronic” are on the rise (Greco & Graber, 2022). But as Greco also observes in her work, which reinterprets as embodied and social crisis, the experience of being treated for metastatic breast cancer, “we lack the theoretical tools to conceptualize crises that do not end” (Greco, 2022,130). Part of the difficulty involved in doing this, has to do with the problem of how to present the state of still being in crisis “after medicine” (Manderson & Smith‐Morris, 2010; Manderson & Warren, 2016; Meyers, 2013, 2016; Samuels & Freeman, 2021). But the aim of this article is to represent the labor of responding to these states, where the subject in daily struggle becomes the focus of ongoing clinical time and attention.

National Health Service (NHS) general practices are sites that attract and accumulate this form of chronic crisis. Even with its many problems of underfunding and understaffing, the NHS retains a legal and moral responsibility for continuing to offer care and treatment to those who need it. This is perhaps even more difficult to uphold in general practices than in other healthcare services, because the requirement to adhere to an open‐door policy in NHS general practice means that its workforce is left having to attend to the fallout from decades of austerity and the privatization of care for human experiences of injury, vulnerability, and loss. With its struggle to keep up with the consequences of having helped lengthen human life and its immersion in mundane concerns, general practice specializes in caring for people whose health issues are “complex” whilst rarely, if ever, reaching the point of being catastrophic. More accurately described as problems of living that cannot be resolved simply by making the right choices at the right time, they can force healthcare to take a different shape from the normative, leading to improvised approaches that are illegible to clinical governance because they are difficult to justify financially or in terms of risk management. Incidentally, many of the doctors who are leaving or thinking of leaving general practice (a higher number than those working within other parts of the NHS), say that one of their main reasons for leaving is that the particular kind of care that general practice offers, which has always been more about the continuity of care than its resolution, is neither valued or understood within the wider healthcare system (Doran et al, 2016; Sansom et al, 2017).

What follows is based on notes taken during observations of NHS General Practitioners watching over some of the chronically unwell as they passed through different stages of what I am referring to as “wearing out.” Their circumstances varied; the list included individual cases of common health conditions like depression or anxiety that tended to drag on or keep coming back without anybody being able to stop the cycle once and for all. It also included treatments for cancer, obesity, heart disease, diabetes, and all the different kinds of exhaustion and fatigue that could be thought of as the bi‐products of multimorbid “living on.” More common were those people whose biological and social pressures would interact in ways that defied attempts to make their chronic conditions “manageable.” To qualify my controversial use of this phrase, “wearing out” which is perhaps most strongly associated with the work of cultural theorist Lauren Berlant, I use it to refer to the slow degradation of health that cannot be prevented using targeted medical treatments, because its causes go beyond individual choice and control. This application deliberately evokes Berlant's insight about how the work of living is implicated in how health deteriorates over time, but the focus here is on how wearing out can be a condition that must somehow be accepted on its own terms, especially within a service like the NHS where the consequences for health of “living on” are central to the work that they do. This article shares Berlant's concern with finding forms to represent the resulting dilemmas in ways that avoid staging them as dramas of medical action versus inaction (Berlant, 2007). What it does not attempt to do is to apply Berlant's slow death analytic² to general practice.

My fieldwork within two general practices happened to coincide with the Covid‐19 pandemic, but even in a period marked by a sudden breakdown of “the ordinary” (Davies, 2020), chronic and “complex” conditions were still the rule rather than the exception. In snatches of time during lunch or between appointments, I followed the working lives of two general practitioners in particular: Claude (a pseudonym, as are all the names used throughout), in his large inner‐city East London practice, and Leo, from the consulting room of his smaller countryside practice in rural Devon. Originally, my aim was to understand what happened when care came detached from any definable notion of therapeutic progress. Claude and Leo worked within a system of healthcare that insisted on orienting every patient contact towards the production of recovery or symptom management, so the temporalities of dying, waiting, and relapsing were overlaid with those of recovery, prevention and productivity. There were very few legitimate forms that clinical labor could realistically take in relation to the long and enduring conditions so commonplace in the NHS, yet in their routine, everyday work, they mostly perceived the breaking down of a human body over time as not necessarily a disaster to be averted, but as a predictable, ongoing event.

Explaining to me that the process of making repairs in general practice rarely had any clearly defined endings, Leo once said, “we don't get people better, that's not what we do”. Not that there were no differences between chronic illnesses and terminal illnesses, which tended to get worse, whatever anybody did to try to influence them, but after reaching a certain stage in trying and failing to “manage” a chronic illness, the line separating optimistic and pessimistic treatment trajectories could blur and lose its relevance next to the more immediate concern of how a person was going to get through the next day, or the next relapse, or the next episode. One of the negative aspects of his labor in this regard—negative in the sense of not being affirmative—was to never really know what the effects of care would ultimately turn out to be, or even if they would be experienced as “care.” Monica Greco described this as the condition of “knowing that you can give, without knowing the positive content of the aim of that giving” (Greco, 2008, 24). In the Surgery, this was a tension that could not be resolved simply by asking patients, “what do you want? How can I help you?” Being without the categories to engage ethically with this aspect of clinical work, is one of the problems that the article seeks to address. The notable omission of “patient voices” in these narratives is a way of allowing this work of giving time, without knowing where it will lead, to emerge. Where patients do appear, some clinical details have been altered to protect their anonymity. It is the dynamic of watching and waiting, rather than any specific condition, that I try to render and understand.

PATIENT INVESTMENTS

In her late eighties, with rheumatoid arthritis and bones that broke easily due to the softening effect of osteoporosis, the likelihood of Rita achieving any objectively “good” clinical outcome was always going to be low. Drug treatments had helped to slow down the bone loss and reduce inflammation. The pain from broken bones had lessened with painkillers. But Leo had noticed in recent months, that Rita was getting more visibly worn down. She had lost weight. Her osteoporosis was causing her more acute pain, and there were other, more worrying symptoms. He suspected they may be pointing to something underlying. They were still in the process of ruling out the possibilities. Leo would send off blood tests to check for cancer and follow up on signs of anything that looked like it might be serious but the priority was helping Rita to deal with the joint pain, which was being made worse by heavy lifting and strenuous activity. For a long time now, Rita had been the sole carer for her husband. They were both in their late eighties, and according to Leo, he was dependent on her for almost everything: “she gets up, works all day, dressing him, helping him to walk, feeding him, then she goes to bed, gets up and does it all over again the next day.” She struggled visibly with the painful after effects but always declined any offers of outside help, insisting on doing it all herself.

It was not uncommon for Leo to be approached by people for help in dealing with the physical and mental strains of becoming a sole carer at an age when their own health was failing. His surgery sat at the center of a rural village community in the South of England where many of his patients had lived their whole lives. Housing and job shortages in the area, combined with longer life expectancy and shortfalls in the care workforce made it more likely that in the last stretch of life, they would be heavily dependent on one another for personal care and companionship. If it turned out that Rita's problems had an underlying physical cause serious enough to require surgery, then her health would decline even further, and she wouldn't be able to provide this care for her husband anymore. Leo said that if this were to happen, they would have no choice but to look at bringing in paid carers as an option. As they had little money saved, they would be eligible for some support from the council to help with funding this, but Rita had been adamant that she should be the one to look after him. Her sole concern, she said, was “to hold their life together for as long it takes for her to outlive him”. Leo took this to mean that whatever the cost to her own long‐term health, caring for her husband was Rita's way of keeping herself going. The only thing that really seemed to matter to her was having the physical strength to keep this arrangement going. She would only agree to the support that made this possible. As the medications she was prescribed for the arthritis, mainly painkillers, did not come between her body and the causes of its degeneration in any meaningful sense, but merely eased her levels of discomfort to the point that she was able to go on with her daily exertions, it was highly likely that Rita would become more disabled as time went on. These were the contingencies that Leo had to find a way of working with.

The default clinical mindset, even in hopeless situations, tends to be to look forward to how some measure of health will be restored at a future time, keeping the body within reach of clinical influence for as long as possible (Cohn et al., 2024), but Leo closely monitored the damage that Rita was doing to herself, in part, so that she could go on doing it for as long as possible. The fractures would eventually heal, but Rita's adherence to his care plans was poor, compromised by all the heavy lifting and handling that she insisted on doing every day to support her husband to dress, wash, and move about from one place to another. Her long‐term health was being put at risk, but Leo had to accept this as one of the limits imposed by the situation. Their appointments were about finding the right balance between conflicting imperatives by working out how to prolong her life's meaningful unfolding, within the constraints imposed by her circumstances. Their time together served a purpose surplus to recovery, where Leo's “letting be” was in a sense, so that Rita could persist in “holding on.” This entailed having to watch for signs that things were getting worse rather than better, waiting to see what harms, injuries and complications would emerge from Rita's struggle to keep what Garcia referred to as her “hold on life” (Garcia, 2015, 318). As, within the system that Leo worked within, time was only valued if it could be shown to be helping Rita to move towards objectively good clinical outcomes, this was not time that could be accounted for in the usual way.

Leo was always careful to adjust his patient's expectations of what medical technologies could realistically achieve. When making a new prescription for anti‐depressants for instance, he prefaced the start of the treatment with the caveat that, medication is not the answer to life's problems: “it's not meant to transform your life, just to lift some of the worst effects of the depression.” Likewise, when Claude, in his inner‐city London practice, was reminded of the shortcomings of medicine which happened often, he would say something like, “we really don't have that many tools to work with,” or “I feel gloomy about this patient,” or “I think we can say by now that his modus operandi probably isn't going to change.” In other words, both had learned to balance the possibilities of drugs and therapies for slowing down or preventing sickness, decline, breakdown, or death, against an awareness of the limitations of using targeted treatments. Occasionally, it would be clear to Leo and Claude that no matter what they did to alter the course of an illness, the illness would take its course anyway. To be positioned as a doctor in relation to illnesses that are going to take their course whatever you do, is challenging to medical ways of knowing that tend to regard life as an object of science. These GPs might be going through the motions of advising and care planning, whilst really, they were engaged in something more like an ethics of non‐intervention that required them to be mediators between life as an object of science, and life as was being lived by human beings (Fassin, 2015). They did not use the term, “watching people wear out” to describe this labor, but I use it to draw attention to the parts of their labor that would usually be edited out, which unsettles assumptions about how the time of an NHS doctor is used, and to what end.

TIME‐LIMITED RECOVERIES

When Giulia called Leo at the surgery one morning, it was to tell him jubilantly that she had been cured. A woman in her late forties with a house in the area and a secure well‐paid job, Giulia had suffered from periods of depression for most of her adult life. She had just completed a Neuro‐Linguistic Programming Course (NLP) paid for by herself, which according to her, had “worked”. Now she wanted to know, “can we stop the medication straight away?” In the weeks that followed, Leo had been surprised and impressed with the results of NLP (“it has changed her mind‐set completely”), but he was cautious about stopping her anti‐depressants straightaway. His view was that the NLP might improve things for a while, but he believed that Giulia suffered from chronic depression, and “you don't question why you might take medication for a long‐term health condition like diabetes, so why question taking anti‐depressants for depression?” Giulia's depression would go through cycles. Leo explained, “she will have crisis moments, like when a family member dies. This is the kind of thing that brings on a crisis, then she gets better for a while. She goes through these episodes.” He talked about this aspect of his work in terms of “watching an episode unfold and learning to read the signs.” This was to avoid making the same mistakes again the next time around. He said, “when people go to see their GP, they're cross referencing with you. They want to know, is this the same? Do we do what we did last time? Or is it different this time? You want to be able to reassure somebody that they've been through this before.” I asked him how he felt about the prospect of carrying on indefinitely with this approach to Giulia's treatment, where he watched one crisis episode unfolding after another. He told me that this was what made the work of a GP rewarding. “The repetition of a cycle is reassuring. You know what to expect and how to help, because you've seen it play itself out before.”

Whilst outwardly sharing in Giulia's optimism about the NLP, Leo had been concerned about what would happen if she were to stop doing all the things that had helped to maintain her mental health up to that point. They'd had “a long chat”, he said, where he had advised her against making it an end goal of the treatment to put the anti‐depressants behind her once and for all. He knew that Giulia might suddenly stop carrying out the daily routines they had built up and break ties with the surgery, and that if/when this happened, he would have no way of knowing what the consequences would be. She had done this in the past following previous recoveries, but then another crisis had come along, followed by another relapse, and the appointments had started back up again, so this was the outcome he felt he needed to plan for.

One of the problems with these intermittent attempts to treat Giulia's depression, was how to reconcile them with evidence approved clinical routes that have been carefully calibrated to achieve the coherence of a diagnosis and a reliable, replicable treatment pathway (Mol, 2002; Law & Singleton, 2003; Yates‐Doerr, 2017). These pathways seemed to imply that with the required level of commitment to drug and clinical oversight regimens, Giulia's depression would respond to treatment, eventually; a claim in keeping with the “promise” of biomedicine to be able to “turn severe diseases into chronic ones” (Greco & Graber, 2022, 1). However, in Leo's experience, the lived realities of chronic depression in treatment often failed to produce any outcomes at all, and the outcomes they did produce could be short‐lived. Trialing one drug after another in the hope that they would find the one that worked was fine, but there would also be times when Giulia was depressed, and this was time that needed to be ridden out somehow.

In the past, Giulia's relapses had followed a predictable pattern. The time when they were most likely to happen was during the weeks following an argument in the family. How she negotiated the feelings of helplessness that flared up following a disagreement with her husband was a subject that she and Leo would return to again and again. He was not a trained therapist, but he told me that he thought of these conversations as therapy. Whether they ever succeeded in averting the downward spiral in her mood that preceded a long episode of depression, he was unable to say with any certainty, but I realized that this was not really the aim of their time together. The aim, if there was one, was the accumulation of therapeutic benefit over time, which he described as “all the little bits adding up”. The underlying assumption was that there were no safe places to return to or aim towards, only varying degrees of mental distress to be tolerated and worked through. Giulia, on the other hand, had been waiting all along for a way out of this—for a treatment that “worked”, and as far as she was concerned, in NLP she had found it. The prospect of an exit from the whole chronic scene of depression, even one that would ultimately prove to have been temporary, held more appeal for her than a return to “living under” the diagnosis (Manderson, 2020). The question of what would happen after the NLP was not something that she seemed interested in discussing. The risk of relapse was real, but the alternative, of staying suspended in endless talk about maintenance and crisis management, had made that a risk worth taking. This was a different framing of health in relation to chronic illness. Maintenance as an organizing principle of time—a “meantime with no end” (Cazdyn, 2012, 13)—had been an obstacle to her getting better.

In clinical terms, Leo explained, Giulia's decision to break off abruptly from her prescribed medication had been unwise. There was the risk of undoing all the months of careful work on symptom management and relapse prevention. But as Kaufman and Fjord point out in their work on anticipatory medicine, treatment regimens that are driven by the quest for risk reduction in which the future is made present through the calculation of risk, shape a “telos of living” that brings its own problems and dilemmas (Kaufman & Fjord, 2011). Leo understood that a clean break represented the possibility of a reprieve from the “relentless future‐thinking about life itself” that having a chronic illness implied (Kaufman & Fjord, 2011, 218), and an escape from the burden of having to be personally responsible for making “rational” choices, even if the escape turned out to be a short‐lived one. He did not actively support Giulia's decision to stop anti‐depressants, but neither did he move against it. His role fell somewhere between being an advocate against the moral authority of clinical governance, to being on standby to help pick up the pieces if/when things fell apart.

For Giulia, the idea of depression as simultaneously ever present and endlessly deferrable blurred the boundaries between health and sickness. Todd Meyers uses the term “afterlives” to refer to these places at the epistemological threshold of therapeutics (Meyers, 2013). “This concerns the notion and limits of cure, of healing, and what stakes (and claims) are at work in defining success and failure—and, fundamentally, how the question of time relates to evidence” (Meyers, 2013, 35). Meyers explains that this is partly a problem of managing expectations around the potential of targeted drug treatments and advancing biotechnologies. On the one hand “making the claim of success seems to tempt fate, begging things to careen wildly off track in the future. On the other hand, claiming failure seems to evacuate all possibility of hope” (Meyers, 2013, 113). One of the markers of difference between NHS and private healthcare providers, is that private providers offering quick resolutions for acute conditions are better shielded from having to bring the question of time to bear on evidence. When privately paying patients are referred back to NHS general practices following a quick course of treatment or therapy, the afterlives of these therapies are referred along with them, and more negative clinical labor flows back into the public sector.

EXHAUSTING THE USES OF MEDICINE

Carrie's primary diagnosis was chronic depression, but this did not explain the extent of her disabilities, or the frequency of her visits to the Practice. In her late thirties, unemployed and welfare dependent, the single parent of two children, both of whom were diagnosed with long term conditions with psychological and physical components, when Carrie called, she was usually calling to ask for help in dealing with the urgent work of getting through the day. Telephone conversations with her tended to be long and rambling. A “blizzard of problems” was how Claude described them. Technically, she was not even Claude's patient, but it fell to him to take a call from her that day as he was the doctor on duty. She often called outside of appointments, sometimes in relation to her own mental health, sometimes regarding the health of her children. Her use of the surgery was so “chaotic”, Claude said, that all attempts at continuity, had ended up being thwarted.

Not unusually for her, Carrie had several reasons for contacting the East London surgery on that particular day. Her main reason for calling had been to ask Claude to forward a letter of evidence to the council confirming her family's vulnerable status. She hoped that the letter would delay or put off the eviction that had been hanging over her family for months. She also wanted to arrange an assessment for her oldest child, Lee. She was convinced he was showing all the signs of having an attention deficit hyperactivity disorder. Claude had reservations about referring Lee to the local child and adolescent mental health service for an assessment. He believed there could be other, more likely explanations. Eventually though, he'd agreed and Carrie had seemed relieved. In Central East London where the number of children living in poverty is amongst the highest in the United Kingdom, it was not unusual for Claude to see children with health problems interlocking with housing and financial insecurity. He said it could be difficult to make defensible clinical judgements when there were so many possible explanations for the appearance of an illness or a condition. He could never claim with any certainty to have identified their root cause. This troubled him, because from a medical perspective, understanding the root cause is necessary for knowing what to treat, and how.

Claude adhered strictly to evidence‐based models of diagnosing and treating depression, but he did not believe that more healthcare would bring about an end to Carrie's mental suffering. At the same time, he was acutely aware that the Practice was one of the very few remaining sources of anything resembling continuing care available to her. Social care services had been involved with the family briefly following reports of a fight between Carrie and a man who was staying with her, but they had ended their involvement as soon as they were satisfied that the home environment posed no immediate risk to the children. The NHS waiting list for intensive, longer‐term mental health support was so long at this point that all new referrals have since been suspended. Where they did exist, other clinically approved routes for treating people diagnosed with depression, including talking therapies, were not always viable. They were time limited, and referral routes to them could exclude someone like Carrie on the grounds that her multiple overlapping mental, physical and social care needs were too complex, or too risky to be treated without the kind of supervision that only an intensive, long term mental health service could provide. At a time when most, if not all other services in the area offering continuing care had been withdrawn, cut, or suspended, it could seem as though certain patients, Carrie included, were “just sort of thrown into our laps”. Claude said that he often felt unable to provide her with the right kind of support, but he saw the value of their appointments more in terms of the very willingness of his Practice to remain open, and to offer her more time without knowing in advance what would come of this (Baraitser et al., 2026).

When speaking about his appointments with Carrie, Claude's tone was not resigned, but it was negative. When I asked him, “why do you think Carrie calls the Practice so often? What is it that you think she wants or needs from you?” he said that it was hard to say—“…a better life? A lift in the heaviness of her mood? For me to stop her children from being ill?” He seemed to see Carrie more as somebody who, in his words, was really just “clinging on by her fingertips”. In the end, it had seemed as though the only real choice for them both, was between stopping, or going on. Claude had not known exactly what it was that Carrie wanted or hoped for from their encounters. The language of process, pathway, and outcome provided them with a structure that meant that they could keep taking steps in the direction of getting better, even if the deferral to “concrete, medical things” had felt inadequate to the scale and the immutability of the problem. When I asked Claude if he could remember any of his actual words to Carrie during his conversation with her, he said he might have been brisk and directive and said something like, “right, let's unpack it then—these multiple things. Let's separate them out.” As he was saying this though, he admitted to not knowing what he would do with the multiple things once they had all been unpacked. Screening for ADHD had given him something to offer that he and Carrie could both hold on to, solid and at least directed towards a future of healing. It separated out the parts of daily struggle that might prove to be treatable, from the familiar background noise of Carrie “struggling in general”. He described their encounters as “having the emotional temperature of somebody depleted in every way.” He said that he could never be certain of whether his attempts at reassurance or problem‐solving had landed as care or as paternalism, or whether they had simply “evaporated into the air”. “Making gestures in the air” is how the Italian feminist, Carla Lonzi described the non‐medical practices of care typically performed by women (Lonzi (1978, 76), cited in Montesi & Calestani, 2021, 9), and much of Claude's work with Carrie could be construed as falling into this category. “What can I do in twenty minutes? I can give her my time, my absolute attention. She might say something—I listen to it—it goes inside—has meaning. It's not just transactional.” The nearest thing to an explanation that he could give of what took place during their contacts was the rationalization that his time, his “self,” was the only thing left to offer as a substitution for anything more durable.

A more situated approach would be needed to understand the forms that choice and collaboration could take within a framing of general practice that substituted some types of chronicity for wearing out, and to account for why Claude would give Carrie the option of going down biomedical routes despite knowing that in the longer term, they probably would not make any difference and could even add to her overall morbidity (Ecks, 2021). Carrie was not a passive recipient of healthcare. She came to the clinic with a list of what might be of use to her in negotiating the effects of the various problems that she was facing on her own terms. What she did with Claude and some of the other GPs she had known over the years, arguably fell more within the definition of “‘a striving’: the play of uncertainty, doubt, and the deepening of intimate relations within a whole weave of life” (Das, 2010, cited in Garcia, 2014, 62). The temporal clinical labor that went along with this striving could include the therapeutic work of waiting—“waiting with, enduring with, staying with, staying alongside, and through the continual offer of simply seeing someone again” (Baraitser & Brooke, 2021). Without the prospect of a good ending to the treatment though, the gesture to offer more time in relation to Carrie's chronic conditions could also be a form of waiting for further deterioration, for the next crisis, for multiple morbidities to emerge.

When he was with Carrie, Claude's ability to imagine that he was taking affirmative action to protect objects of clinical concern could easily be overwhelmed by all the evidence to the contrary. When this happened, the distinctions separating “natural” decay due to life being lived, from “manmade” decay pursuant to what Berlant termed, “regimes of living that force biological life not just to appear, but to endure and appear in particular ways” (Berlant, 2007, 756) grew blurred. Then, chronic disease ceased to function as a normalizing screen for the more insidious or senseless reasons behind how quickly some bodies could wear out by comparison with others. This is when he would get stuck in the grey area between medical intervention and non‐intervention, which altered the very telos of his labor because his time was repurposed in service to endurance instead of recovery,

In the United Kingdom, the negativity that attaches to the labor of watching people wear out is unevenly spread. The declining working conditions, housing insecurity, rising costs of living, air pollution, and social immobility in Central East London, made it more likely that Claude's attempts to treat his patients’ chronic illnesses would be frustrated by forces outside of his control. The lower ratio of GPs to patients also made a difference to how it felt to be a GP for somebody whose health was getting worse over time. Claude struggled to provide Carrie with the continuity and regularity of contact, which for Leo in his quieter village surgery, were the prerequisites for negative labor to be allowed to accumulate over time into something good and worthwhile. Both Claude and Leo were Senior Partners within their Practices. Both had completed their medical training in the United Kingdom and were settled close to their families in the communities they had long served. But the national picture suggests that this labor is falling disproportionately onto migrant doctors trained outside of the United Kingdom, many of whom are obliged to fill vacant posts in areas further away from existing migrant communities: neglected coastal towns, ex mining towns, and deprived inner‐city areas in the North of England (Esmail et al., 2017). What they have in common are downward economic trajectories, lower GP to patient ratios, and a higher prevalence of difficult to treat chronic conditions, particularly depression.

CONCLUSION

ʻʻI think the profession of a healer is not a practice that

facilitates attaining or obtaining wholeness forever, but a

practice of bearing witness to all the parts—the parts that

have been apart, are apart, and will remain apart—being hereʼʼ

Johanna Hedva. Letter to a Young Doctor.

Accepting that there are limits to what medicine can do, could be seen as a dangerous move to adapt to a world in which a person's wearing out is normalized instead of being prevented. Ghassan Hage warns that there are consequences for how people adapt to living without forward movement. Those who try to normalize it or to turn it into some kind of achievement “as something that one is proud to do” (Hage, 2009, 105), might be overlooking what is self‐defeating and doomed about it. In contrast, Berlant's approach to modulating harm and “decomposition” by watching how they take place in ordinary time, works to extend definitions of death and crisis, to make them take in its durative and everyday effects by zoning in on the reproductive work of “getting through it” (Berlant, 2007, 764). This reinsertion of durational time into medicine is unsettling for medical ethics because it challenges notions of health understood in simple terms of gaining access to the right treatment at the right time. The substitution of recovery for a focus on endurance, forces uncomfortable questions to surface, about the difference between giving people access to life changing, life prolonging healthcare, and giving them what they need to go on struggling through lives that they cannot substantially alter. Without the pretense that the subject in daily struggle is moving towards a future horizon where things can always potentially look or feel different, questions of “how to” (intervene, provide care, treat effectively), run into more disorientating enquiries about “what is” (intervention, care or treatment, in this context?): “What else might we base our claims on? What boundaries do we evoke in our judgments? What—and whose—are the terms of these boundaries? And how do we go about writing these qualifications into the stories we tell?” (Yates‐Doerr, 2014).

England's national long term sickness strategy is still overwhelmingly driven by the goal of “treating conditions before they become crises” (Great Britain. Department of Health and Social Care, 2023), but the temporalities of chronic crises I observed in these general practices, were sharply at odds with those of preventative medicine. The correlations between chronic illness, everyday hardship and infrastructural failure, were obvious to all the GPs I spoke with. Closely related to their problem of how to treat the body in chronic crisis, is the ethnographic question that has preoccupied the writing of this article, of how to represent care in relation to a body in chronic crisis, when the care in question is a non‐event? In other words, “how does one study something that is not happening?” (Borgstrom et al., 2020). Annemarie Mol wrote memorably about caring for chronic conditions by attentively monitoring them in real time, with the clinician imagining a continuous person beyond the surgery (Mol, 2008). Picturing his own labor in similar terms, Claude compared the type of monitoring that he did, romantically, as I thought at the time, to watching ships sailing away in the distance. He followed the twists and turns of those he knew were likely to run into difficulty along the way, not to step in at the critical moment, but (and only when possible) to steady their passage. He checked in on those he worried about when he could and tried to keep track of them, not always successfully. In these situated instances where the best intentions of medicine were repeatedly overturned by bodies falling in and out of capacity, disability and despair, the main (non)event of clinical labor was to stay attentive to how a particular body was falling apart without necessarily seeking to rush it back to health. This did not stop Claude or Leo from taking the necessary steps to prevent future diseases, injuries, or more disabilities from materializing, but they did this from within the understanding that sometimes a person's sickness needed to be allowed to unfold away from ideas of progression, flourishing and living well (Samuels & Freeman, 2021). Others have written about the need to focus on what it means to live (and wait) well with chronic illness (Wahlberg, 2017), or to find ways of “flourishing beyond the biomedical” (van Blarikom et al., 2024). I have tried to describe how the time is made for a person to wear out on their terms. The “durational labor” (Baraitser, 2017) that happens on a small scale whenever treating a person diagnosed with one or more chronic conditions, means having to watch that person deteriorate periodically, or get progressively more unwell over time. Some recalibrations of the timing of medical care have been needed to make this thinkable as a problem of the clinical everyday. They share aspects of the methods used by medical anthropologists towards the “uncasing” of the case (Yates‐Doerr & Labuski, 2023). The clinical cases that I had the chance to observe did not run along any kind of linear treatment pathway. They tended to be repetitive, discontinuous, sometimes edging towards better health, at other times falling away from anything that looked or felt like health, traversing successive afterlives and what Jain referred to as “the folds of various representations of time’” that follow on from a prognosis (Jain, 2007, 80). Different concerns emerge when the most chronic parts of chronic cases are “uncased,” returning repetition, death, vulnerability, and decay to the scene of the clinical encounter.

Alison Kafer invites us to consider, as “normal,” the time of slowly wearing down as one waits for even more violence to come. Thought about in this way, the gesture of episodically watching over and attempting to strengthen a person's hold on life might be a way of sustaining the body as it waits “for (additional) injury, for (more) trauma, for (quicker or slower) death” (Kafer, 2021, 421). Quite often for Claude and Leo, this was about doing what they thought they needed to do to keep the whole intact, so that things might run a little longer.