Are all lives and deaths equal?

The question of whether all lives and deaths are equal inevitably evokes strong emotions, but it’s a question that lies behind much of our thinking on how to respond to Covid-19. Most deaths from Covid-19 occur in people over 70 (“three score and ten”), and deaths under 40 are vanishingly rare. (Many young people died in previous pandemics: how would we cope if that was the case now?).

We discussed the question on the Lancet Commission on the Value of Death, and some thought that it wrong even to discuss the question. I tried to write something for the Commission to consider, but with so much else to consider it fell by the wayside. The increasingly emotional debate over how best to respond to the pandemic has prompted me to share the piece. I saw it as a starting point for discussion not a final statement.

The Covid-19 pandemic has brought into sharp focus the questions of whether all lives and deaths are equal and who should take priority if life-saving resources are limited. The religions of the book believe that only God should decide who will live and die and that man overreaches himself by making such decisions. This belief was not challenged when medicine had little or no capacity to defeat death, although the religions had to deal with war and capital punishment.

Some deaths are preventable and avoidable, whereas others are inevitable. Deaths of children from diarrhoea or measles, usually in low and middle income countries, are qualitatively different from deaths of frail elderly people in care homes in high income countries. It seems sensible and right to prioritise resources to prevent deaths that can be prevented and avoided.

Medicine does have powers to hold off death even in the frail elderly, and within some specialties, particularly intensive care and organ transplantation, decisions have to be taken over who will be given priority. In many ways these decisions were more acute when life-extending treatments first appeared and were in short supply– for example, fifty years ago in Britain people over 40 or people with renal failure and diabetes would not be offered renal dialysis.

Nobody argues that decisions on priority should be based on income, social class, ethnicity, disability, or sexual orientation, or any social factor, but two factors promote continuing debate—age and whether a person’s condition is self-inflicted (they have, for example, smoked or drunk or eaten too much).

Many would argue that it is to oversimplify to consider conditions being “self-inflicted” in that people’s social circumstances, genes, and personalities rather than rational choice lead them to adopt unhealthy behaviours. Nevertheless, surgeons may require patients to lose weight or stop smoking before agreeing to operations which are expected to prolong life or refuse liver transplants to patients with alcoholic liver disease who are unable to stop drinking.

Doctors argue that they take these decisions simply on clinical grounds rather than on moral or social grounds. They give priority to the people most likely to benefit from any medical intervention. This is a principle of intensive care and means in circumstances as in many low and middle income countries where intensive care facilities are very limited a young man shot in a gang fight will take precedence over a middle-aged priest with diabetes and a heart attack simply because the young man, who was healthy until the moment he was shot, is more likely to benefit from intensive care than the older man.

Clinical decision making will thus mean that the young will often taken precedence over the old and that those who have damaged themselves through tobacco, alcohol, food, or drugs will come behind those who are healthier (and possibly older).

But should age always be a factor when deciding priorities? There are three main arguments for this position. Firstly, the concept is widely accepted. It is captured in the well-known phrase “women and children first” but also in the thought experiment where only two of a grandparent and grandchild can be saved: very few opt for tossing a coin to decide. Secondly, the “fair innings” argument says that those who have had a full life (or at least the chance of one) should give way to those who have not had the same chance. Thirdly, giving priority to the young means that more lives (and certainly more life-years) will be saved.

One argument against using age is that invoking a particular cut-off age may be little better than a lottery if somebody a day before his or her 70th birthday is given precedence over somebody who is a day over 70; and this can be further complicated if the 70-year-old is much fitter than the 69-year-old. A second argument is that the “fair innings” argument is also arbitrary: for all sorts of reasons—for example, prolonged time as a political prisoner—an older person may have had less chance of fulfilling him or herself than a younger person. Thirdly, to discriminate against the elderly is to suggest that they are of less worth or importance than younger people.

Governments understandably shy away from being explicit about giving priority to the young, but in practice they do. Consider, for example, how in Britain and most European countries health services have been given  attention, funding, and equipment far greater than that for care homes, which serve old people almost entirely. Then England’s National Institute for Health and Care Excellence uses cost per QALY (quality adjusted life year) to make decisions on which treatments should be available, and by definition a treatment that cures a 20-year-old will produce more QALYs than one that cures an 85-year-old.

This is as far as I got in the piece I wrote for the Commission, but I’ve added this now:

Perhaps in the end we answer this question for ourselves through personal experience. My mother, who is approaching 91, has been eight years in a care home and has had no short-term memory for 12 years. When she was in her 60s (as I am now) she wrote a letter with me to the BMJ calling for the right to assisted dying for people with oncoming dementia. https://www.bmj.com/content/331/7520/842.5 She dreaded dementia because she’d see it overtake her mother. During her years in the home my mother has been cheerful and brought joy to many, but when I saw her two weeks ago she was miserable and told me she’d rather be dead. I simply can’t see how her death would be equivalent to the death of any of my four grandchildren.

The philosophy of Harold Skimpole: “let us ride our rocking horses”

When Esther, Ada, Richard, and Mr Jarndyce listen in “Bleak House” to Harold Skimpole, who once trained in medicine, adumbrate his philosophy they are “enchanted.” You feel that Dickens is equally enchanted. We are all enchanted. Let us ride our rocking horses.

“Go your several ways in peace! Wear red coats, blue coats, lawn sleeves; put pens behind your ears, wear aprons; go after glory, holiness, commerce, trade, any object you prefer; [edit journals, fear Covid-19, run the country, perform on the stage, nurse the sick] only—let Harold Skimpole live!

I covet nothing. Possession is nothing to me. Here is my friend Jarndyce’s excellent house. I feel obliged to him for possessing it. I can sketch it and alter it. I can set it to music. When I am here, I have sufficient possession of it and have neither trouble, cost, nor responsibility. My steward’s name, in short, is Jarndyce, and he can’t cheat me. We have been mentioning Mrs Jellyby [the very opposite of Skimpole with her mad campaigning on Africa while neglecting totally her own family]. There is a bright-eyed woman, of a strong will and immense power of business detail, who throws herself into objects with surprising ardour! I don’t regret that I have not a strong will and an immense power of business detail to throw myself into objects with surprising ardour. I can admire her without envy. I can sympathise with the objects. I can dream of them. I can lie down on the grass—in fine weather—and float along an African river, embracing all the natives I meet, as sensible of the deep silence and sketching the dense overhanging tropical growth as accurately as if I were there. I don’t know that it’s of any direct use my doing so, but it’s all I can do, and I do it thoroughly. Then, for heaven’s sake, having Harold Skimpole, a confiding child, petitioning you, the world, an agglomeration of practical people of business habits, to let him live and admire the human family, do it somehow or other, like good souls, and suffer him to ride his rocking-horse!”

I envy you your power of doing what you do. It is what I should revel in myself. I don’t feel any vulgar gratitude to you. I almost feel as if YOU ought to be grateful to ME for giving you the opportunity of enjoying the luxury of generosity. I know you like it. For anything I can tell, I may have come into the world expressly for the purpose of increasing your stock of happiness. I may have been born to be a benefactor to you by sometimes giving you an opportunity of assisting me in my little perplexities. Why should I regret my incapacity for details and worldly affairs when it leads to such pleasant consequences? I don’t regret it therefore.”

The more we listened, the more gaily Mr Skimpole talked. And what with his fine hilarious manner and his engaging candour and his genial way of lightly tossing his own weaknesses about, as if he had said, “I am a child, you know! You are designing people compared with me” (he really made me consider myself in that light) “but I am gay and innocent; forget your worldly arts and play with me!” the effect was absolutely dazzling.

Walking across the US Mexico Border in the lands of the Tohono O’odham Nation

In 2012 I walked across the Us Mexico Border and back again. I was visiting the lands of the Tohono O’odham Nation, an ancient people who say that the border crossed them rather than them crossing the border. I wrote a blog about my visit, https://blogs.bmj.com/bmj/2012/04/02/richard-smith-a-people-to-fade-or-flourish/ but I’m surprised to see that I didn’t describe our walk across the border, but I remember it clearly.

We drove through the beautiful desert and the clear air to the border, which is marked by large concrete blocks designed to stop a four-by-four driving through. The land belongs to the Tohono O’odham Nation, and they had always refused to allow a wall to be built. Although you can’t drive through, you can easily walk or drive a motorbike through. We did walk across the border, and it felt very good to be able to do so. For the people and the land this is no border but another piece of desert.

As soon as Trump began to rant about his wall to keep out Mexicans, I wondered whether he would be able to build his wall on the sacred land of the Tohono O’odham Nation. I’ve looked today, and just what I feared would happen has happened. This is from the “New York Times” of 2 March 2020. https://www.nytimes.com/2020/02/26/us/border-wall-cactuses-arizona.html

“Work along the border, according to tribal leaders of the Tohono O’odham Nation who live on both sides of the border, is blasting ancient burial sites and siphoning an aquifer that feeds a desert oasis where human beings have slaked their thirst for 16,000 years.

The outcry by tribal citizens reflects the latest phase in the quarreling over the border wall, after federal courts allowed the Trump administration to speed construction by waiving dozens of laws, including measures protecting endangered species and Native American burial sites. Federal officials have cited President Trump’s national emergency declaration in 2019, aimed at curbing unauthorized immigration, as justification for the waivers.”

Here’s my blog from 2012, remembering a wonderful visit:

The symbol of the Tohono O’odham, a native American tribe, is a man in a maze (see below). All of us, they believe, are born into a maze. We have to make our journey through the maze to try and reach the centre of peace and serenity. Often we are lost, and when we are lost, say the elders of the tribe, we must go back to the beginning. At the moment the whole Tohono O’odham people are deep in the maze and going back to the beginning may be the best way for them to go forward.

I had the privilege last week of spending a whole day with the Tohono O’odham people, meeting the leaders of the tribe as part of the University of Arizona’s conference New Frontiers in Global Health Leadership. We met in the new and beautifully designed Cultural Centre of the tribe. It’s close to the centre of the 2.8 million acres of the land of Tohono O’odham, all of which is desert and mountain. The Cultural Centre looks across the desert to the striking profile of the sacred mountain of the people, Baboquivari Peak. The Tohono O’odham believe that this mountain is the navel of the world, where the first people emerged.  High on the mountain is a cave of I’itoi, one of the three gods who created the world. The Tohono O’odham travel there to make offerings to I’itoi and to pray. In past days when they were attacked by Spaniards, Apaches, and other tribes, the warriors would climb to the cave to seek strength.

The desert between Cultural Centre and the sacred mountain is not empty, sandy desert, but desert filled with mesquite, cactus (the big ones 250 years old), and for those who know how to find them a whole host of edible and medicinal plants, including tepary beans, chola buds, and wild spinach. The desert is beautiful, still, and sweet smelling, but this can be a very hostile environment—baking hot on summer days and freezing cold on winter nights. Our people believe, said Bernard Siquieros, the curator of the Cultural Centre, that by eating the plants that are strong enough to survive the heat of the summer and the cold of the winter we grow strong.

This is a land with long horizons, across the often flat desert to the distant mountains. The land of the Tohono O’odham is 2.8 million acres, an area the size of Connecticut.  The United States has 566 registered tribes, but the land of the Tohono O’odham is the second biggest tribal land area in the country—after the Navajo Nation. (I must confess that—perhaps like you—I had never heard of the Tohono O’odham, whereas I have heard of the Apaches, Navajo, Sioux, and Cherokee. The Tohono O’odham know that they are not as well known as they would like.) Originally their land was much bigger, stretching north to Phoenix, south to Hermosillo in Mexico, West to the Gulf of California, and East to Colorado. But in the 19th century without consulting the Tohono O’odham, the US and Mexican governments drew their border through the lands. “We didn’t cross the border, it crossed us,” said Verlon Jose, the Chairman of the Chukut Kuk district, one of the 11 districts into which the land is divided and the one with the longest border with Mexico.

It is being on the border that presents the Tohono O’odham with one of their biggest challenges. Although the desert may look still, “all kinds of things are happening out there,” said Jose. Some 700 to 800 people a day are trying to cross into the US across the desert, said Ned Norris Junior, the Chairman of the Tohono O’odham people (the Chairman is the equivalent of the President in the US, is elected, and serves for a limited term). Nobody knows exactly how many people are trying to get through, but, according to Norris, it was very few until 9/11 and the North America Free Trade Agreement (NAFTA), but then increased to 200 a month and then to 1500 a day.

The big increase is because of the “funnel effect.” The land of the Tohono O’odham has a 75 mile border with Mexico, and the people are very clear that they will not allow a high fence to be built across their land—not least because for centuries and until very recently they moved backwards and forwards across the border without interference. Either side of the tribal lands there is a fence, and so both illegal immigrants and drug runners are funneled into the lands of the Tohono O’odham.

Many of those who try to cross the desert do not make it, and bodies and human remains are found regularly. There is also a lot of litter and danger, particularly from those running drugs. Jose described how he has been held up at gunpoint more than once.

One result of all this is that many of the Tohono O’oldham are nervous about venturing into the desert to collect traditional foods and medicinal plants. This in its turn contributes to two of the other major problems of the people: obesity and diabetes. The people who spoke to us spoke wonderfully and often with great humour, but it was impossible not to observe that most of them were obese, many of them morbidly so. And half of the adults are diabetic, one of the highest prevalences in the world.

The nation has comprehensive programmes to prevent and manage diabetes, obesity, cancer, and domestic violence, and there is “the HOPP” (Healthy O’odham Promotion Program). But these programmes face a formidable task, and there is perhaps a deeper problem—the decay of the traditional culture of the Tohono O’odham.

Siquieros described to us a summit of the people to try and answer the question, “What is our culture?” The first answer was “language.” The culture is embedded in the language, and the people have strong oral traditions, passing down stories from generation to generation. There was no written language until the mid 80s. Few people can read or write the language, but the older people all speak it. An exhibit in the museum showed, however, that fewer than 10% of people under 18 speak the language.

The brute statistics of language are that any language that has fewer than a million speakers is likely to disappear. There are around 30 000 enrolled members of the Tohono O’odham tribe with 14 000 living on the tribal lands, 1400 across the border in Mexico, and 14 000 in other parts of the US. Many of those people do not speak the language, and so despite the energy of the people running the Cultural Centre there must be anxiety that the language will disappear.

The second answer to the question of “What is our culture?” was “ceremonies.” Many of these are no longer practised, and Jose told us about his son trying to remember all the songs and words from one particular ceremony where only two elders still remember everything.

“Values” was the third answer, and Siquieros told us that the traditional values include respect (for each other and the land), sharing, family, and industriousness. We saw the sharing in all of the presentations with each one being shared by several people. Leadership among the Tohono O’oldham is inclusive.

The mention of family reminds some of a terrible time earlier in the 20th century when children from the tribe were taken from their families and sent to boarding schools hundreds or even thousands of miles away. The children might be beaten in those schools for speaking their own language. One woman told us of how her grandmother had been sent to boarding school. The Boarding Bus would tour the tribal lands looking for children to catch. “Like dogcatchers,” I couldn’t stop myself saying. “The result,” said the woman, “was that mothers didn’t know how to mother and children didn’t know how to be mothered.” If you want to destroy a culture you take away the children.

The fourth answer to the question was “foods.” When people walked long distances harvesting the desert they had both lots of exercise and healthy foods. Diabetes was rare. For centuries even millennia the Tohono O’odham lived in harmony with their hostile environment. They have been displaced from most of their lands by people living lives that are not sustainable. It’s hard to see this as progress.

Most of our party came away uplifted by a fascinating day. I was hugely impressed by the Tohono O’odham’s attempts to overcome their problems, which, they pointed out, they needed to take the lead in solving. I did, however, feel fearful about the future, but when I asked Siquieros about the future he said he felt very good. He saw young people wanting to rediscover the culture of the Tohono O’odham, going back to the beginning of the maze.

Why Karl Ove Knausgaard writes

In his booklet, Inadvertent, Karl Ove Knausgaard tries to answer the question “Why I write.” The book is based on a lecture he gave as part of a series of the Windham Campbell lectures on “Why I write.” Ultimately, I think it would be fair to say, Kanausgaard doesn’t know exactly why he writes. There is no definitive answer, but through his search for an answer he comes up with interesting observations on not only writing but also reading and literature. Rather than try to synthesise his thinking in my words I’ve simply quoted below what seemed to me key passages.

What Knausgaard does succeed in describing clearly is his journey as a writer. Most of it was struggle, silence, disappointment, rejection, loss of confidence, and failure before he arrived at the six extraordinary volumes of My Struggle, which have made him famous way beyond Norway. The main thing that separates successful writers from would-be writers—indeed, from successful anything o would-be anything—is persistence, determination, and tolerance of rejection, failure, and disappointment.

The first quote below—”I write because I’m going to die”–comes from the very beginning of Inadvertent, but Knausgaard is quoting another unnamed writer. Yet, it may be the main reason that Knausgaard writes or that any of us does anything, including reproduce. Now there is a possibility with climate change that we are all going to die, but I doubt that the extinction of the species will provide the same stimulus to create as our individual extinctions—perhaps because we need the thought that there will be somebody around to consume what we create.

Writing

That is what writing is: creating a space in which something can be said.

Writing is precisely about disregarding how something seems in the eyes of others, it is precisely about freeing oneself from all kinds of judgements and from posturing and positioning. Writing is about making something accessible, allowing something to reveal itself.

Sitting still and waiting for them [hedgehogs in the dark] to come out and become accessible to my gaze is the novel’s way of thinking, while the …the inadvertent stumbling over them in the dark and giving it a kick is the logic of poems and short prose. In both cases its happens inadvertently…thoughts are the enemy of the inadvertent, for if one thinks about how something will seem to others, if one thinks about whether something is important or good enough, if one begins to calculate and pretend, then it is no longer inadvertent and accessible as itself, but only what we have made it into.

It is one thing to know something, another to write about it, and often knowing stands in the way of writing.

What happens when one writes is that the “I,” which is really only a means to get a handle on things, a way of arranging everything one experiences, lets go so that the foreign and the others move closer to our own form, as represented by literature—as the system for transporting culture, thoughts, insights, feelings, images, notions, from one person to the other–-so that writing is as much about losing and giving back as it is about creating and taking.

To create a fictional space requires either great strength or great ignorance.

For me all writing is blind and intuitive, it either works or it doesn’t, and any explanation of why a novel turned out the way it did will always be an ex post facto rationalization.

Reading

I read them [books] alone, and yet it never felt like that, for while you were reading, you were always together with somebody else.

Thoughts and feelings are not mutually exclusive…[in books] they are brought together. Reading is a different way of thinking.

To read is to be the citizen of another country, in a parallel realm which every book is a door to.

And that is exactly how to read isn’t it? Certainly, we open ourselves to another voice, which we turn into ourself, for when we read, what  we feel are our own feelings, our own fear and enthusiasm, sorrow and joy, and wen we reflect the reflections are our own, performed by our own self, but only as apprehended by the other, annexed by the other.

Literature

Literature by its very nature always seeks complexity and ambiguity, and that monologic claims of truth about the world are antiliterary.

Literature was a hiding place for me, and at the same time a place where I became visible…and this, an outside place where what is inside becomes visible, is still what literature is to me.

The contradiction between the illimitable that dwells within us and our simultaneous limitation and earthboundness is the driving force behind all literature and art, or so I believe, but not only that; the longing to equalize the difference, suspend the contradiction and simply exist in the world, undifferentiated from it, is also an important part of religious practice.

Other observations

The chasm separating death’s solemnity from life’s unceremoniousness

Seen from a great distance a life can be summed up in a single sentence

We live in a particular place in a particular country with a particular culture, and we belong to a particular stratum within that culture. All of us sum up our lives in this way, that is what we call identity; and we sum up the world we inhabit in similar ways, that is called culture.

Follow-up thoughts on whether Sweden maybe right about Covid-19

I’ve just heard David Nabarro from the WHO on the radio, and he emphasised that the people not government hold the key to responding to Covid-19. We need to follow simple rules, and I can see why people in Sweden might be much more able and willing to follow the rules than people in other European countries.

The rules are:

  1. Keep socially distanced from those who are not from your household
  2. Wash your hands regularly, particularly after visits outside the home
  3. Wear a mask when with others not from your household
  4. Completely isolate yourself (plus or minus your family) if you develop symptoms for 14 days or until you get a negative test (remembering it may be a false negative)
  5. Get tested (if you can)

These are simple rules, and if everybody knew them and followed them we would still have infections but no surges.

Most people must have heard these messages, but they are in Britain mixed in with lots of conflicting messages. The stop-start messages from the British government are confusing. Plus many people don’t understand why they should follow them. Worse they don’t trust the government. Then in Britain you don’t have to go far to see people breaking the rules—probably for a variety of reasons. People may wonder why they have to follow he rules if others aren’t.

Sweden has avoided the stop-start messages and, as the figure shows, the Swedish government is more trusted than the British one.

Plus importantly Sweden has emphasised that the pandemic will last a long time (avoiding things like Boris saying it might be over by Christmas), and it has not asked Swedes to make such extreme changes, meaning surely that it’s easier to sustain the changes in behaviour.

Could Sweden have got it right with Covid-19?

Sweden stood alone in Europe in not opting for a severe lockdown when cases of Covid-19 began to rise in the Spring. As a result, the New York Times called Sweden “a pariah state,” and Sweden had had higher death rates than most countries in Europe, although lower than Britain. But, as I write this on 18 September, the difference in the number of cases in Sweden and most of the rest of Europe is striking. Most countries in Europe have a rapid rise in cases, whereas Sweden does not (see below). Spain, which had one of the most severe lockdowns, has one of the steepest increases.

The reason for the difference may well be that Sweden has more immune people, probably mostly younger people.

We knew from the beginning of the pandemic that it was likely to last for  years and that most of us had no immunity. We would either catch the infection or try to avoid it by minimising our contact with others. Eventually either enough of us would have caught the disease to generate the much-maligned herd immunity or many of us would be vaccinated. Either way it was going to be a long haul, and years of minimising contacts would mean no work, schools, or fun.

Sweden could behave differently from other countries because public health officials not politicians decide how to respond to the pandemic. This sounds frighteningly anti-democratic, but the decision to do it this way was reached through democratic means.

In a fascinating interview in the Financial Times, . https://www.ft.com/content/5cc92d45-fbdb-43b7-9c66-26501693a371  Anders Tegnell, the chief public health official in Sweden, describes the thinking of him and his colleagues  “At the outset we talked very much about sustainability, and I think that’s something we managed to keep to. And also be a bit resistant to quick fixes…We see a disease that we’re going to have to handle for a long time…” Tegnell describes a lockdown as “using a hammer to kill a fly.” You need “a strategy that can work for years if need be, rather than constant chopping and changing as seen in the rest of Europe.”

Crucially to my mind, Tegnell and his team thought about “public health in the broadest sense,” recognising the importance of education, work, and meeting with friends for health. “We are not just working with communicable diseases, we are working with public health as a whole.”

Sweden has concentrated its efforts against the virus on places where it’s most likely to be spread—places of entertainment where many people gather. Those places have strict rules on social distancing. Tegnell is unconvinced by the value of face masks, and they are not much seen in Sweden. Face masks are “more of a statement than actually a measure…Face masks are an easy solution, and I’m deeply distrustful of easy solutions to complex problems.” I’m the same, but I can understand why easy solutions and quick fixes are attractive to politicians.

The same thinking makes Tegnell cautious about the “silver bullet” of a vaccine. The idea that “once vaccine is here we can go back and live as we have always done…[is] “a dangerous message…because it’s not going to be that easy.”

When the FT journalist spoke to Tegnell in the spring he said that “it would be in he autumn when it became more apparent how successful each country had been.” As Britain looks close to going into another national lockdown, Sweden seems to have a adopted a better strategy. But all judgements must be provisional as pandemics are unpredictable, and Tegnell does expect local spikes in cases.

My visit to US Mexico Border: the 20-foot fence between the rich and poor worlds

We’ve watched two television programmes about the journey along the US Mexico Border of Sue Perkins, a British comedian. She does a marvelous job of capturing the joy, colour, and excitement but also the tragedy of what some call Amexicana. https://www.bbc.co.uk/programmes/m000mfw7 I was reminded of my two visits to the Border, one where I could walk across https://blogs.bmj.com/bmj/2012/04/02/richard-smith-a-people-to-fade-or-flourish/ and one below where I stood on the American side in Nogales, a city wrenched in two by the wall. (I’ve also crossed the Border through immigration in Juarez and Tijuana.)

I’m standing looking at a twenty foot high fence that at night is lit as brightly as daylight. It snakes away over dry hills to both east and west like a vulgar, modern version of the Great Wall of China. I’m in Nogales, a town in both Arizona and Mexico that is sliced in half by the fence. This is the border between the rich and poor worlds.

          We’ve been talking to a young officer from Border Patrol. He’s responsible for about half a mile of the border. He sits in his van from 6 am to 2 pm every day waiting for “jumpers,” people making a break for the rich world. At the moment there’s about one jumper a day, and when I ask if he catches them he says I should talk to his superior. “Mostly, I’m a deterrent,” he says. His white van is covered in iron caging for protection when he’s “rocked,” when people hurl boulders over from the Mexican side. He’s from Texas, has been in the job for a year, and hasn’t been rocked.

          As we talk, very loud rap music with a heavy bass begins to come out of the Mexican house we are looking at, which is perhaps three yards from the other side of the fence. “That’s for us,” says a colleague. I imagine that it says “Up yours, gringos.” Behind us is a beautiful view of the mountains of Southern Mexico.

          When the fence was first built it was solid, but that was much less secure than the present fence, which is effectively huge railings and can be seen through. The officer can see the jumpers coming. In downtown Nogales the houses are even closer to the fence, and at one point the solid fence caused terrible flooding on the Mexican side because heavy rain couldn’t drain away as it had done for millennia.

          I think of other walls and fences. I’ve seen similar fences in Belfast. I crossed the Berlin Wall in 1982 and remember the worldwide jubilation and excitement when it came down in November 1989. I’ve not seen it, but perhaps the most terrible of all these fences is the one that separates Israel and Palestine. I think too of the many prisons I visited in the early 80s. High fences mean prisons, and I wonder which side of this fence is the prison.

          The Border Officer is the first line of defense, but there are at least two more behind him. Most of the migrants don’t jump, rather they come across the desert, often in large, organised groups. Earlier in the morning we drove to the point west of Nogales that is currently the most popular route. The routes change in an endless game of cat and mouse between the migrants and Border Control. What strikes me is the still beauty of the spot. The desert is not flat but rather rolling hills with mountains closer to the border. It’s not empty desert, rather it’s filled with cactuses and dry shrubs.

    It may be beautiful, but it’s also lethal. We are about 12 miles from the border, and the migrants who cross this way have to walk for a day and a half before they even reach the Mexican side of the border. For most of the year the desert is baking during the day and cold at night, and it’s very disorientating, making it easy to get lost.

          Many of those who try to cross are ill prepared. They come from Central America and Chiapas and Oaxaca in Southern Mexico. They are used to jungle not desert. Sometimes women start wearing high heels. In the last year there have been just over 200 deaths, but many bodies go undetected. My colleagues tell me the story of a grandfather resident in the US whose daughter and grandson tried to cross. The daughter died, and the grandson, dehydrated and delirious, was picked by the Border Patrol and deported. The grandfather couldn’t bear the idea of his daughter’s body lying unburied in the desert and so began a search for her with friends. They searched for six weeks and found four other bodies before they found his daughter’s body.

          I try to imagine how desperate you must be to attempt such a crossing. And even if you get as far as the road where we’re standing you may still be caught. As we drive back from Nogales to Tucson we are stopped and have to show our passports. And anybody in Arizona committing an offence at any time, perhaps jumping a stop light, can be asked to show their documents. If they can’t produce them they are deported straight away or jailed and then deported. More people have been deported during Obama’s presidency than during Bush’s second term, explaining one reason why Obama is not popular with Hispanics, who voted for him overwhelmingly in 2008.

          My friends tell me the story of an “undocumented” woman who had been in the US for 32 years and has four children. She was picked up for “behaving suspiciously” and is facing deportation. She might be deported to anywhere along the 2000 mile border, and the border towns are filling up with the deported. They are some of the people most desperate to get back—to rejoin their families.

          The possibility that you might be stopped at any time has created a lot of fear in Arizona. Even those who are fully legal may be fearful. I understood something about this in a tiny way when my wife and I arrived in the US this time. We flew into Dallas Fort Worth and had a three hour stop over before our connection to Tucson. We stood in line for almost two hours and began to fret that we’d miss our connection. We asked somebody to help, and he took us to the front of a line. When called we went forward, but the officer was immediately hostile.

          “How did you get there?”

          “One of your assistants put us there.”

          “He’s not allowed to do that. Why did you get put forward?”

          “We thought we might miss our connection?”

          “That’s not our problem. You should have made a more sensible booking.”

          “But other people connections were moved up the line,” I said rather pathetically.

          “Look I’m here every day. I know the rules. That’s not allowed.”

          He continued in this bullying vein for quite some time. It clearly gave him pleasure. We stood there like guilty children, feeling very powerless. It was tempting to say, “Look, sonny, we’ve stood here for two hours watching endless repeats of a facile video with people welcoming us to America. You have twenty booths with only three staff, and when we finally get to the front of the line, directed by one of your staff, you tell us off and bully us. You are no doubt taking out on us the inadequacies of your self, life, and relationships, for which we feel sorry, but this is no way to welcome people to America.”

          We would, of course, have been sent straight home and perhaps banned from entering the US again. So we smiled weakly and looked at our feet. If this is how we feel—rich gringos, laden down with degrees, able to speak English, and entering the US legally (albeit with a little illegal cheese)—how can poor undocumented migrants with little English feel

          But some people are bolder. My colleagues told me the story of a Mexican woman who lived legally in the US for decade and had 11 children, all US citizens. She was fierce, knew her rights, took no nonsense from anybody, and was all about helping others. She lived on the border and went back to a time when it was easy to go backwards and forwards across the border.

          She helped out in an orphanage, and one day was taking a pile of clothes to the children. Both the US and the Mexican officials told her it was not allowed to take used clothes into Mexico. Her response was to walk a little way down the road, ring the orphanage on her cell phone, and then start throwing the clothes over the fence. Nobody stopped her.

          Two years later she died, and a staunch and traditional Catholic she’d made it clear to her children, mostly daughters, that she wanted to be buried on the Mexican side within 24 hours of dying. Her daughters tried getting the necessary papers to take a body across the border but were told it was impossible within 24 hours. They were, however, like their mother, and undeterred in three cars they took their mother’s coffin to the border. The officials asked for the papers but were told they didn’t have them. Then you can’t cross, said the officials.

          At this point the daughters, dressed glamorously in black suits with black high heels and thick scarlet lipstick, grabbed their mother’s coffin and ran across the border. I imagine this as the opening scene in a Francis Ford Coppola film, and it’s an image of the border that I prefer to the young border officer staring at the fence eight hours a day waiting for jumpers.

Is cancer still the best way to die?

I was asked to write the blog below by George Lundberg, who is in his 90s and was the editor of JAMA when I was editor of the BMJ. He has a blog where he calls himself Curious Dr George, asks people questions, and asks them to respond. The blurb at the beginning makes the context clear, and the blog can be seen at https://cancercommons.org/latest-insights/is-cancer-the-best-way-to-die/

In 2014, the prestigious medical research journal The BMJ published a controversial piece called “Dying of cancer is the best death.” Here, our Curious Dr. George asks the author of that piece, Richard Smith, CBE, FMedSci, if and how his thoughts on death have since evolved. Dr. Smith was Editor of The BMJ from 1991 to 2004 and is currently Chair of the Lancet Commission on the Value of Death.

Curious Dr. George: Your 2014 BMJ blog post on dying of cancer precipitated quite a robust discussion. Since then, the fields of precision oncology and immunotherapy have developed a lot, although perhaps not yet realizing their full potential. You currently chair the Lancet Commission on the Value of Death, from which a report is forthcoming. Looking back at 2014, have developments in precision oncology and immunotherapy changed your thinking about death?

Dr. Smith: In 2014, as you note, I unintentionally created global furor by arguing in a blog post that cancer is the best way to die. Nothing else that I’ve ever written has created such a storm, but many physicians, aware of the three broad alternatives, agreed with me. Sudden death may seem attractive but can leave great pain among those you love. Organ failure is prolonged and messy, and the long, slow death of frailty and dementia is exhausting for everybody. Dying from cancer, I wrote: “You can say goodbye, reflect on your life, leave last messages, perhaps visit special places for a last time, listen to favorite pieces of music, read loved poems, and prepare, according to your beliefs, to meet your maker or enjoy eternal oblivion.” I recognized that I may have succumbed to romanticism, but I argued that such a death “is achievable with love, morphine, and whisky.” “But,” I warned, “stay away from overambitious oncologists.”

Now, you tell me that precision oncology and immunotherapy have developed and ask me if my attitude has changed. I have a friend with metastatic malignant melanoma who is kept alive by immunotherapy and would probably be dead if it were still 2014.

For the past three years, I have been chairing the Lancet Commission on the Value of Death, and we hope to publish our report in spring of next year. Our starting point is that medicine and society have developed an “unhealthy” relationship with death. We find that few health professionals disagree, and most people have stories of grisly deaths in hospital. Indeed, with the ongoing COVID-19 pandemic we have become used to people who are dying in intensive care communicating with their loved ones only through iPads and accompanied only by masked and gowned strangers.

What is wrong with how medicine and society approach death? Firstly, death, many would argue, is the most important event in our lives. Plato called philosophizing an apprenticeship for death, and the Irish thinker Kevin Toolis argues that “The world makes sense to us because we die, not because we don’t.” We can surely all agree that death is a community, family, and spiritual event—not simply a medical event. The job of culture, often assigned to religion, is to give meaning to death. Medicine cannot provide meaning, and yet in high-income countries (and increasingly in poorer ones) death has degenerated to a medical event with reduced family, community, and spiritual involvement. People are unfamiliar with death and dying, as the dying and the dead are hidden in hospitals. “The experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing,” wrote Atul Gawande in his book Being Mortal.

A second problem is that aggressive treatment may often prolong life but increase suffering. The American physician Eric J. Cassell taught us that persons, not bodies, suffer, and stretching out the process of dying and treating patients only hours from death with cytotoxic drugs, antibiotics, and even operations often increases suffering.

A third problem is the high and disproportionate expenditure at the end of life. Even if this expenditure were to benefit the individual, which it often doesn’t, it makes no sense to the broader community. Resources are diverted not only from more cost-effective health care but also from the factors that shape health—education, housing, urban design, and reducing poverty.

The answer of the Lancet Commission is to rebalance death and dying, shifting it from a medical event to something that is owned by families and communities with support from health professionals. In case such a vision seems Utopian, we can point to where it is already happening—in Kerala in South India and in Compassionate Community programs that are developing around the world.

What would such a vision mean for precision oncology and immunotherapy? I would favor them if they can prolong life without prolonging suffering and without increasing the division between the few in the world who have excellent end-of-life care and the majority who have no access to opiates and even the most basic palliative care. But are they part of medicine’s Faustian pursuit of immortality, which is explicit among well-funded companies in California and implicit in conventional medical research that attempts to cure every disease? And can precision oncology and immunotherapy be part of a world where health professionals are supporters not leaders at the end of life, and we regain some connection with the meaning of death? I’m not sure, but I’m skeptical.

Agonisingly apt paintings of good and bad government

My reading this morning seemed agonizingly apt, as if sent to me by God. I’ve been reading in Hisham Matar’s book A Month in Siena about Ambrogio Lorenzetti’s murals on good and bad government painted in the Palazzo Pubblico in Siena in 1338. The rulers of the city made their important decisions surrounded by these paintings. My reading is apt because Britain currently has one of the worst and most incompetent governments it has ever had. Yesterday it announced proudly that it intended to break the law and renege on a treaty with the European Union that it signed only a year ago.

The paintings are filled with enough iconography to keep scholars active for millennia and justify hours studying the paintings.

The Allegory of Good Government covers one wall. The Common Good, the largest figure, has Wisdom, faith, Charity, and Hope flying above him, Justice, Peace, Fortitude and Prudence to his left, and Magnanimity, Temperance, Justice to his right. Justice, you’ll notice, Boris, features twice. Below are the citizens. You eye travels the picture, but most prominent is Peace, a woman in white reclining on armour, perhaps showing it’s unused or that peace rests on military strength.

The Effects of Good Government shows prosperous, peaceful people going about their business and pleasure amidst exquisite architecture.

The Effects of Bad Government is dominated by a cross-eyed devil who is more foolish than evil—and inevitably invokes Boris.

I feel that I must try and see the originals before I die, and I propose that the Royal Academy now ask Britain’s greatest painter to paint modern-day versions for the room where the British Cabinet meets.

Were Neville Chamberlain and the appeasers utter failures?

Born in 1952 to a mother who was evacuated and a father who was  a German prisoner of war, I’m thoroughly familiar with Neville Chamberlain’s promise of  “peace for our time” after he returned from negotiating with Hitler in 1939. Chamberlain is one of the great examples of historical failure. To be called an appeaser is still a strong insult. What I hadn’t grasped is how almost everybody was an appeaser in the mid-30s and how popular he was when he made his promise. So has popular history misjudged Chamberlain?

Tim Bouverie sets out to answer that question and to tell the story of appeasement in the highly readable Appeasing Hitler, which is filled with colourful quotes and extracts from letters, diaries, and newspaper stories of the time.

The climax of the book—the bit that everybody knows—is Chamberlain returning from Europe declared “peace for our time.” This is how the BBC described his journey from the airport to Downing Street:

“Here he comes, preceded by two policemen, mounted policemen, and the car can hardly turn the corner because the press of people have come out and stopped it for the time being. People here are getting wildly excited and it’s one of the most impressive sights I’ve ever seen: a completely unorganised, spontaneous welcome to a man who has done his best for his country. It’s the most wonderful spontaneous effort: nobody has told them to come here, nobody was asked to come here. But somehow people of every walk of life have drifted here to certify their presence.”

Carried away with the emotion, Chamberlain leaned out of a window in Downing Street, waving his piece of paper and saying:

“My good friends, this is the second time in our history that there has come back from Germany to Downing Street peace with honour. I believe it is peace for our time. We thank you from the bottom of our hearts … Now I recommend you go home and sleep quietly in your beds.”

These are the letters and gifts that Chamberlain received in the next weeks:

“Over 20,000 congratulatory letters were delivered to 10 Downing Street, along with fishing rods, umbrellas, flowers, chocolate, salmon flies, slippers, pipes, kippers, cigars, champagne, cider, pictures, ‘beautifully knitted prize winning socks’, crates of apples, a saddle of Welsh lamb, grouse, a ‘wedding cake’, a grand piano, opera glasses, clocks, watches, ‘a replica Jersey milk can’, a four-leafed shamrock, bulbs, gingerbread, tweed, German hock, clotted cream, ‘lucky horse-shoes’ and a pair of Dutch clogs.”

The French, who were equally grateful, tried to give him a country house beside a trout stream—fishing was his passion.

There are, Bouverie arguments, four arguments that appeasement was not all wrong. Firstly, it gave Britain and France time to rearm and prepare for war. Secondly, public opinion would not tolerate a war before 1939; and the countries of the Empire were strongly against war, meaning an earlier declaration of have would have split the Empire. Thirdly, it was only when Hitler invaded Czechoslovakia in 1939 that he showed he could not be trusted. Fourthly, to try to avoid the horrors of war it was reasonable to make concessions to Germany, which had been so ill-treated in the Treaty of Versailles.

Bouverie dismisses all these arguments.

Neither Britain nor France was well prepared for war in 1938, but the Germans were in a worse state. Bouverie argues that “the strategic advantage lay with the Allies in the autumn of 1938.” He also argues, as did some of the anti-appeasers (Churchill being the most prominent) that an earlier war, when Germany was much less well prepared, could have been shorter and saved many lives and much destruction.

As Chamberlain’s reception when he returned from Munich showed, the British were hungry for peace. Most people in the 30s had personal experience of the appalling deaths and damage that resulted from the First World War. People would do anything to avoid another war, and appeasement has to be seen against his backcloth. People, including high officials, also believed that London and other cities would be bombed flat. Many historians accept that because of public opinion appeasement was almost inevitable, but Bouverie argues with data that public opinion was not so much against war and that “had Britain’s political leaders spelled out the nature of the German and the need to resist it—as Churchill did—then pubic opinion could have appeared very different.”

The biggest failure, argues Bouverie, was failing to “perceive the true character of the Nazi regimen and Adolf Hitler.” The intention for world domination and the destruction of Jews can be read in Mein Kampf, which was published in 1925. Desperate to avoid war, the appeasers kept on thinking that they could trust Hitler, who like some modern-day politicians, had no compunction in lying. Chamberlain was a rational, tolerant man who, wrote Duff Cooper, “had never met anybody in Birmingham [where he was mayor] who in the least resembled Adolf Hitler. He had always found that the people he had met, whether in business or in local government, were not very dissimilar to himself – they were reasonable and honest and it had always proved possible, with a certain amount of give and take, to make a deal with them that should prove satisfactory to both sides.” We now tend to see Hitler as evil incarnate, but when you first encounter a man so far removed from the mean you are almost bound, almost mathematically, to misjudge him—especially when you desperately want to believe what he is telling you.

Bouverie at the end of his book utterly condemns Chamberlain, but I worry that he may concentrate too much on an individual. Chamberlain was like all of us a person of his times and surrounded by others who thought similarly. Although by the end of the book you think that popular history has reached the right verdict on Chamberlain, you understand why—and you feel sympathy for the man.

These are the quotes I took from the book:

The sense that the Allies were to blame for the Nazis was critical to the mentality from which appeasement developed. If Britain and France had ‘created’ national socialism then, logically, they could ‘appease’ it by redressing the grievances on which it had prospered.

British anti-Semitism, though shocking and offensive today, was broadly social and snobbish, rather than racial and extremist – a clear contrast with Nazism.

“The Government simply cannot make up their mind, or they cannot get the Prime Minister to make up his mind. So they go on in strange paradox, decided only to be undecided, resolved to be irresolute, adamant for drift, solid for fluidity, all powerful to be impotent. So we go on preparing more months and years – precious, perhaps vital to the greatness of Britain – for the locusts to eat.” Churchill

For Chamberlain the trip had been a ‘great success’. As Henderson confirmed in a series of enthusiastic letters, it had achieved its objective, which was to create a positive atmosphere from which it would be possible to ‘discuss with Germany the practical questions involved in a European settlement’.

[The delusions of Neville Chamberlain] ‘It gives one a sense of the wonderful power that the Premiership gives you’, he wrote to his sister Ida from the Duke of Westminster’s Highland estate on 8 August 1937. ‘As Ch[ancellor] of Ex[chequer] I could hardly have moved a pebble; now I have only to raise a finger and the whole face of Europe is changed!’

‘Must we have a death-struggle with Germany again?’ wondered the Permanent Head of the British Foreign Office. ‘Or can we stand aside?’ The former did ‘no one any good’. Would the latter ‘be fatal?’ Cadogan was inclined to think not. In a few short sentences, however, he had articulated the dilemma over which Western policy makers were to agonise for the next seven months.

If it was oratory that was needed, then Churchill was undoubtedly the man. Yet for most Conservatives, the former Liberal, architect of the Gallipoli disaster, opponent of Indian reform and champion of Edward VIII during the Abdication crisis remained an object of considerable distrust.

The Prime Minister’s policy was, in Lord Hugh Cecil’s memorable phrase, akin to ‘scratching a crocodile’s head in the hope of making it purr’.

This bravura performance of defeatist realpolitik provoked Lord Winterton, Chancellor of the Duchy of Lancaster, who argued that on this basis the Government might as well acquiesce ‘in the invasion of Kent or the surrender of the Isle of Wight’.

This was indeed a problem for the anti-appeasers. Of those whom Chamberlain, paradoxically, labelled ‘the weaker brethren’, only Duff Cooper controlled a major department while the rest, as Oliver Harvey lamented, were rather a poor lot: ‘Oliver Stanley flabby, Elliot a windbag, De La Warr sound but a very light weight, Morrison now quite dégonflé [deflated], it seems.’91 Outside the Government, Eden was still unwilling to take a public stand and Churchill was considered too self-serving and bellicose for most Conservatives to rally around.

You ‘could always appease lions by throwing Christians to them but the Christians had another word for it’.

Dorothy Parker’s crack that Chamberlain was ‘the first Prime Minister in history to crawl at 250 miles an hour’

The prevailing attitude was captured by a pamphlet entitled England: A Dying Oligarchy, in which the author, the novelist and journalist Louis Bromfield, set out ‘in good Birmingham’ style an account of everything which had resulted or would result from Britain’s policy of appeasing the dictator states: Immense loss of prestige throughout Europe, Asia and America. 

1.      Immense damage to the cause of Anglo-American friendship and American respect for England. 

2.      Immense losses to British investors, as well as foreign investors, both in revenue and capital. 

3.      Immense comfort and stimulus to the dictators and lawless elements of the world. 

4.      The loss of British leadership of the democracies. 

5.      Foreign domination of the Mediterranean, so vital to the life of the British Empire.

On 27 April, despite the noteworthy opposition of the Labour Party, the Commons passed the Military Training Bill. It was a limited measure – encompassing only men aged twenty and twenty-one – but it was a momentous signal of intent: the first time that compulsory military service had been introduced in Britain, during peacetime, in nearly 300 years.

Chamberlain had admitted that he was ‘more afraid of a peace offer than of an air raid’, since it would encourage the ‘peace-at-any-price people’.31 That many such people existed he was in no doubt. Only the previous week 1,860 letters, out of a total of 2,450 received, had urged him to ‘Stop the war’ by one expedient or another.

Were Neville Chamberlain and the appeasers utter failures?

Born in 1952 to a mother who was evacuated and a father who was  a German prisoner of war, I’m thoroughly familiar with Neville Chamberlain’s promise of  “peace for our time” after he returned from negotiating with Hitler in 1939. Chamberlain is one of the great examples of historical failure. To be called an appeaser is still a strong insult. What I hadn’t grasped is how almost everybody was an appeaser in the mid-30s and how popular he was when he made his promise. So has popular history misjudged Chamberlain?

Tim Bouverie sets out to answer that question and to tell the story of appeasement in the highly readable Appeasing Hitler, which is filled with colourful quotes and extracts from letters, diaries, and newspaper stories of the time.

The climax of the book—the bit that everybody knows—is Chamberlain returning from Europe declared “peace for our time.” This is how the BBC described his journey from the airport to Downing Street:

“Here he comes, preceded by two policemen, mounted policemen, and the car can hardly turn the corner because the press of people have come out and stopped it for the time being. People here are getting wildly excited and it’s one of the most impressive sights I’ve ever seen: a completely unorganised, spontaneous welcome to a man who has done his best for his country. It’s the most wonderful spontaneous effort: nobody has told them to come here, nobody was asked to come here. But somehow people of every walk of life have drifted here to certify their presence.”

Carried away with the emotion, Chamberlain leaned out of a window in Downing Street, waving his piece of paper and saying:

“My good friends, this is the second time in our history that there has come back from Germany to Downing Street peace with honour. I believe it is peace for our time. We thank you from the bottom of our hearts … Now I recommend you go home and sleep quietly in your beds.”

These are the letters and gifts that Chamberlain received in the next weeks:

“Over 20,000 congratulatory letters were delivered to 10 Downing Street, along with fishing rods, umbrellas, flowers, chocolate, salmon flies, slippers, pipes, kippers, cigars, champagne, cider, pictures, ‘beautifully knitted prize winning socks’, crates of apples, a saddle of Welsh lamb, grouse, a ‘wedding cake’, a grand piano, opera glasses, clocks, watches, ‘a replica Jersey milk can’, a four-leafed shamrock, bulbs, gingerbread, tweed, German hock, clotted cream, ‘lucky horse-shoes’ and a pair of Dutch clogs.”

The French, who were equally grateful, tried to give him a country house beside a trout stream—fishing was his passion.

There are, Bouverie arguments, four arguments that appeasement was not all wrong. Firstly, it gave Britain and France time to rearm and prepare for war. Secondly, public opinion would not tolerate a war before 1939; and the countries of the Empire were strongly against war, meaning an earlier declaration of have would have split the Empire. Thirdly, it was only when Hitler invaded Czechoslovakia in 1939 that he showed he could not be trusted. Fourthly, to try to avoid the horrors of war it was reasonable to make concessions to Germany, which had been so ill-treated in the Treaty of Versailles.

Bouverie dismisses all these arguments.

Neither Britain nor France was well prepared for war in 1938, but the Germans were in a worse state. Bouverie argues that “the strategic advantage lay with the Allies in the autumn of 1938.” He also argues, as did some of the anti-appeasers (Churchill being the most prominent) that an earlier war, when Germany was much less well prepared, could have been shorter and saved many lives and much destruction.

As Chamberlain’s reception when he returned from Munich showed, the British were hungry for peace. Most people in the 30s had personal experience of the appalling deaths and damage that resulted from the First World War. People would do anything to avoid another war, and appeasement has to be seen against his backcloth. People, including high officials, also believed that London and other cities would be bombed flat. Many historians accept that because of public opinion appeasement was almost inevitable, but Bouverie argues with data that public opinion was not so much against war and that “had Britain’s political leaders spelled out the nature of the German and the need to resist it—as Churchill did—then pubic opinion could have appeared very different.”

The biggest failure, argues Bouverie, was failing to “perceive the true character of the Nazi regimen and Adolf Hitler.” The intention for world domination and the destruction of Jews can be read in Mein Kampf, which was published in 1925. Desperate to avoid war, the appeasers kept on thinking that they could trust Hitler, who like some modern-day politicians, had no compunction in lying. Chamberlain was a rational, tolerant man who, wrote Duff Cooper, “had never met anybody in Birmingham [where he was mayor] who in the least resembled Adolf Hitler. He had always found that the people he had met, whether in business or in local government, were not very dissimilar to himself – they were reasonable and honest and it had always proved possible, with a certain amount of give and take, to make a deal with them that should prove satisfactory to both sides.” We now tend to see Hitler as evil incarnate, but when you first encounter a man so far removed from the mean you are almost bound, almost mathematically, to misjudge him—especially when you desperately want to believe what he is telling you.

Bouverie at the end of his book utterly condemns Chamberlain, but I worry that he may concentrate too much on an individual. Chamberlain was like all of us a person of his times and surrounded by others who thought similarly. Although by the end of the book you think that popular history has reached the right verdict on Chamberlain, you understand why—and you feel sympathy for the man.

These are the quotes I took from the book:

The sense that the Allies were to blame for the Nazis was critical to the mentality from which appeasement developed. If Britain and France had ‘created’ national socialism then, logically, they could ‘appease’ it by redressing the grievances on which it had prospered.

British anti-Semitism, though shocking and offensive today, was broadly social and snobbish, rather than racial and extremist – a clear contrast with Nazism.

“The Government simply cannot make up their mind, or they cannot get the Prime Minister to make up his mind. So they go on in strange paradox, decided only to be undecided, resolved to be irresolute, adamant for drift, solid for fluidity, all powerful to be impotent. So we go on preparing more months and years – precious, perhaps vital to the greatness of Britain – for the locusts to eat.” Churchill

For Chamberlain the trip had been a ‘great success’. As Henderson confirmed in a series of enthusiastic letters, it had achieved its objective, which was to create a positive atmosphere from which it would be possible to ‘discuss with Germany the practical questions involved in a European settlement’.

[The delusions of Neville Chamberlain] ‘It gives one a sense of the wonderful power that the Premiership gives you’, he wrote to his sister Ida from the Duke of Westminster’s Highland estate on 8 August 1937. ‘As Ch[ancellor] of Ex[chequer] I could hardly have moved a pebble; now I have only to raise a finger and the whole face of Europe is changed!’

‘Must we have a death-struggle with Germany again?’ wondered the Permanent Head of the British Foreign Office. ‘Or can we stand aside?’ The former did ‘no one any good’. Would the latter ‘be fatal?’ Cadogan was inclined to think not. In a few short sentences, however, he had articulated the dilemma over which Western policy makers were to agonise for the next seven months.

If it was oratory that was needed, then Churchill was undoubtedly the man. Yet for most Conservatives, the former Liberal, architect of the Gallipoli disaster, opponent of Indian reform and champion of Edward VIII during the Abdication crisis remained an object of considerable distrust.

The Prime Minister’s policy was, in Lord Hugh Cecil’s memorable phrase, akin to ‘scratching a crocodile’s head in the hope of making it purr’.

This bravura performance of defeatist realpolitik provoked Lord Winterton, Chancellor of the Duchy of Lancaster, who argued that on this basis the Government might as well acquiesce ‘in the invasion of Kent or the surrender of the Isle of Wight’.

This was indeed a problem for the anti-appeasers. Of those whom Chamberlain, paradoxically, labelled ‘the weaker brethren’, only Duff Cooper controlled a major department while the rest, as Oliver Harvey lamented, were rather a poor lot: ‘Oliver Stanley flabby, Elliot a windbag, De La Warr sound but a very light weight, Morrison now quite dégonflé [deflated], it seems.’91 Outside the Government, Eden was still unwilling to take a public stand and Churchill was considered too self-serving and bellicose for most Conservatives to rally around.

You ‘could always appease lions by throwing Christians to them but the Christians had another word for it’.

Dorothy Parker’s crack that Chamberlain was ‘the first Prime Minister in history to crawl at 250 miles an hour’

The prevailing attitude was captured by a pamphlet entitled England: A Dying Oligarchy, in which the author, the novelist and journalist Louis Bromfield, set out ‘in good Birmingham’ style an account of everything which had resulted or would result from Britain’s policy of appeasing the dictator states: Immense loss of prestige throughout Europe, Asia and America. 

1.      Immense damage to the cause of Anglo-American friendship and American respect for England. 

2.      Immense losses to British investors, as well as foreign investors, both in revenue and capital. 

3.      Immense comfort and stimulus to the dictators and lawless elements of the world. 

4.      The loss of British leadership of the democracies. 

5.      Foreign domination of the Mediterranean, so vital to the life of the British Empire.

On 27 April, despite the noteworthy opposition of the Labour Party, the Commons passed the Military Training Bill. It was a limited measure – encompassing only men aged twenty and twenty-one – but it was a momentous signal of intent: the first time that compulsory military service had been introduced in Britain, during peacetime, in nearly 300 years.

Chamberlain had admitted that he was ‘more afraid of a peace offer than of an air raid’, since it would encourage the ‘peace-at-any-price people’.31 That many such people existed he was in no doubt. Only the previous week 1,860 letters, out of a total of 2,450 received, had urged him to ‘Stop the war’ by one expedient or another.