“We are here on Earth to fart around, and don’t let anybody tell you any different.”

This comes from an interview with Kurt Vonnegut. I’ve loved it for 20 years and you might too.

“I work at home, and if I wanted to, I could have a computer right by my bed, and I’d never have to leave it. But I use a typewriter, and afterward I mark up the pages with a pencil. Then I call up this woman named Carol out in Woodstock and say, “Are you still doing typing?” Sure she is, and her husband is trying to track bluebirds out there and not having much luck, and so we chitchat back and forth, and I say, “Okay, I’ll send you the pages.”

Then I go down the steps and my wife calls, “Where are you going?” “Well,” I say, “I’m going to buy an envelope.” And she says, “You’re not a poor man. Why don’t you buy a thousand envelopes? They’ll deliver them, and you can put them in the closet.” And I say, “Hush.”

So I go to this newsstand across the street where they sell magazines and lottery tickets and stationery. I have to get in line because there are people buying candy and all that sort of thing, and I talk to them. The woman behind the counter has a jewel between her eyes, and when it’s my turn, I ask her if there have been any big winners lately.

I get my envelope and seal it up and go to the postal convenience center down the block at the corner of Forty-seventh Street and Second Avenue, where I’m secretly in love with the woman behind the counter. I keep absolutely poker-faced; I never let her know how I feel about her. One time I had my pocket picked in there and got to meet a cop and tell him about it.

Anyway, I address the envelope to Carol in Woodstock. I stamp the envelope and mail it in a mailbox in front of the post office, and I go home.

And I’ve had a hell of a good time. I tell you, we are here on Earth to fart around, and don’t let anybody tell you any different.”

Vonnegut

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When death took a holiday

I’m working on a Lancet Commission on the Value of Death, and I’m gathering material. That’s what led me to my 2009 review in the BMJ of José Saramago’s novel Death at Intervals. http://www.bmj.com/content/338/bmj.b941  I and the rest of the team will be grateful for any material or thoughts you might like to share on the value of death.

“If,” wrote Ludwig Wittgenstein, “you were to think more deeply about death, then it would be truly strange if, in doing so, you did not encounter new images, new linguistic fields.” José Saramago, the Portuguese author who won the Nobel prize for literature in 1998, prefaces his novel  Death at Intervals with this quotation—and presumably saw it as a challenge. He rises to the challenge with aplomb, and Wittgenstein would not be disappointed.

Saramago’s first way to think about death is to imagine that it stops. The “death strike” begins with the New Year in an unnamed country. It takes a while for people to realise that nobody is dying, and the health minister immediately gets into a mess by telling the people, as is the instinct with politicians, that nobody should be alarmed. A cardinal is, however, alarmed: “Without death there is no resurrection, and without resurrection there is no church.”

But once the people realise that death is no more “a high tide of collective joy sweeps the country.” The joy is, of course, short lived for some. Undertakers are the first to ask the government for support—rather as banks, car manufacturers, and private schools are doing now in Britain. The answer is for the undertakers to bury cats, dogs, and other domestic animals with full funereal rites. Next to complain are the directors of hospitals, which have rapidly filled and become “cemeteries of the living.”

In the middle of a characteristic Saramago sentence, more than two pages long, he writes of how “the rhomboid of the ages will be swiftly turned on its head, with a gigantic, ever-growing mass of old people at the top, swallowing up like a python the new generation, who, transformed for the most part into nursing or administrative staff to work at these eventide homes…” Such a future, which we are experiencing in the real world where death is only partly interrupted, is, he writes, “the worst nightmare that could ever have assailed a human being.”

The people, as they quickly begin to realise that the end of death is far from a cause of joy, demonstrate their initiative by taking relatives who are near death over the border, where they die and can be buried—overtones here perhaps of euthanasia. The “maphia, with a ph” quickly turn this transportation of the nearly dead into a business and blackmail the government into supporting them.

Eventually death has had enough. She—because death for Saramago is female—sends a violet coloured letter to the director general of the television station announcing that she’ll resume work at midnight and that henceforth people will be told a week in advance of their death. The note is grammatically weak, and one newspaper publishes a corrected version. This infuriates death, who sends a letter for publication: “Dear sir, I am not Death, but death, Death is something of which you could never conceive, and please note, mister grammarian, that I did not conclude that phrase with a preposition, you human beings know only the small death . . . one day you will find out about Death with a capital D.”

People hear of their forthcoming deaths in violet coloured letters delivered by the postman, and, unsurprisingly, the advance warning is hated. Death personally signs 250 letters a day but is very taken aback when one letter keeps coming back. Manifested as a beautiful 36 year old, death sets off to explore, and the last quarter of the book becomes small scale and personal in contrast to the large public stage of the first three quarters.

The letter that kept returning was intended for a 50 year old cellist, and death tracks him down. Seduced partly by the charms of the cellist and his dog and partly by Bach’s sixth suite for solo cello (and who couldn’t be?), death ends up in bed with the cellist, and, as she neglects her duties, the book ends with the same sentence with which it began: “The following day, no one died.”

Can doctors, many of whom deal with death every day, learn something from this fictional examination of death? I think so. The book might be thought of as a series of thought experiments, and they illustrate the centrality of death to human experience. Ivan Illich accused doctors of destroying cultural mechanisms of dealing with death in their implicit attempt to defeat it, and Saramago, while hardly mentioning doctors, warns too against attempts to push back death too far.

Death at intervals

Stories from Bangladesh: “Easy, I’ll get another wife”

At breakfast in Dhaka I read in the newspaper that 87% of married women in Bangladesh have been abused. Abuse may be physical, sexual, psychological, or financial.

At dinner I talk to a Bangladeshi woman who is running a research programme to improve the detection and management of people with hypertension. She tells me about a woman whose husband did not allow her to travel to a clinic for treatment. The researcher met with the man and asked him why he didn’t allow his wife to go for treatment.

“Who will do the cooking if she goes?” He answered.

“Who will do the cooking if she dies?”

“Easy, I’ll get another wife.”

The next day I meet another researcher who describes an experience of a woman with severe loss of blood after giving birth. Money was needed urgently to pay for transport to a clinic and treatment. The husband refused to pay, saying again that he could easily get another wife.

In Bangladesh half of women are married under 18 and 18% by the time they become15. This is the second highest rate of child marriage in the world.

But things are not all bad. Both the present and past prime ministers are women. Bangladesh has female literacy rate (58%) more than double that of Pakistani (27%) and a low fertility rate, two factors that account for it achieving the Millennium Development Goals and mother and child mortality. (I did, however, here stories of female literacy rates declining.) And every day when I’m in Bangladesh I meet highly capable and influential women leaders.

Singing “The Winkle Song” around the world

Last week I sang The Winkle Song to around 600 Bangladeshis from a stage in a car park in Dhaka. They seemed to like my performance, which made me reflect on other times I’ve sung the song around the world.

I always introduce The Winkle Song by saying that it’s a song that can be sung only by people who can’t sing. That’s my excuse. I can’t remember where I learnt it, but I tell people it’s a song that has emerged from the back streets of South London, just like I have. A winkle, I explain, is a small blue shellfish; you need a pin to winkle out the winkle itself, which is something like a small worm–but very tasty to the true South Londoner. Most people have never heard of a winkle, and if they have they confuse it with a whelk or even a cockle.

Here are the words of The Winkle Song:

One Saturday afternoon for tea

I fancied a luxury

So I went down to old Mother Wrinkles

Bought myself a pennyworth of winkles

Took them home, put them on a plate

‘appy as can be

For my old woman and her seven kids

And all the family

Were picking all the big ones out

Picking all the big ones out.

When I saw my pennyworth of winkles

All the big ones gone

It made me rave and shout

For my old woman and her seven kids

We’re picking all the big ones out.

Bangladesh was once East Bengal in the days of the Raj, and I have sung The Winkle Song in West Bengal as well–on a boat on the Hoogli River in Calcutta. I sang it to the senior officers of the Indian Medical Association, most of whom were drunk on Indian whisky. I wasn’t feeling well and so was not drinking. They asked me for a song, and once again The Winkle Song was wheeled out. In their drunken state the officials liked it so much they wanted another song. That was a problem as I know only one song, but then my scouting days came back to me and I sang I’ve Got Sixpence. They asked for another song, but I said I knew no more. So they asked me to dance, and I did. My dancing, if it’s possible, is worse than my singing, but they liked it. Although editor of the BMJ and had given the named speech at their conference. I was simply a performing monkey–and I didn’t mind. Making a fool of yourself works well in every culture (although I reflect that Nazis might not have liked The Winkle Song).

On another occasion I sang The Winkle Song to the world leaders of surgery in the Melbourne Art Gallery. I was sat at the top table with the presidents of umpteen surgical colleges. I had given the president’s lecture, which I’d entitled “Is Surgery An Anachronism In The Age Of Evidence Based Medicine.” It hadn’t gone down well. I was supposed to say a few words at the dinner on behalf of foreign guests, and I hadn’t intended to sing. But during the meal the waiters began to sing, revealing themselves to be opera singers. Their performances, mixed with Australian wine, inspired me, and I decided that I’d sing too.

This wasn’t my best performance of The Winkle Song as half way through, perhaps affected by the wine, I forgot the words. I’ve never been invited back.

But perhaps my strangest performance was at the Oxford Union. I’d been invited to contribute to a debate on the 60th anniversary of the NHS. The evening hadn’t been smooth as I’d not realised I should have been wearing evening dress–and at dinner I’d mistaken the Tory Member of Parliament, Louise Mensch, for a student.

There were far too many speakers, and I was scheduled to be the last. The audience was lapsing into torpor by the time I was finally asked to speak–at about 11.15. I’d carefully prepared my speech, but I thought that it would be cruel to inflict another speech on the somnolent audience. So instead I launched into The Winkle Song, dancing and stamping on the old wooden floors to emphasise the rhythm. The audience instantly awoke. The applause was rapturous. It was my greatest performance.

winkle

 

 

Ah, the English

He’s walking around the garden
Past the jasmine, under the mango tree,
Admiring the water lilies
In the cool rainfall pond.
Pale trousers, pink shirt
What’s that he’s carrying?
A small pot,
It’s surely something sacred
Perhaps holy water
Or the ashes of his father.
But no, later inquiry
Reveals it to be marmalade,
Which is, of course
Sacred to the English.
Ah, the English.

Seeing through the eyes of a three-year-old

Alexander, our three-year-old grandson, is riding in a trolley in a supermarket when he becomes very excited. “Look, look,” he shouts in his loud voice. My wife looks but can’t see what is exciting him. “Look, look,” he shouts again. My wife still doesn’t know what is exciting him, but then she realises it’s a woman in a burqa, which is embarrassing. She tries to divert Alexander, who is fascinated, and luckily the woman disappears from sight.

Alexander has never seen a woman in a burqa before. He’s recently come to London from Mexico, and Muslims are vanishingly rare in Mexico. We are very used to women in burqas, which is my wife couldn’t see what Alexander was seeing. But on reflection you can see why he was fascinated. He has seen cartoon pictures of ghosts in books and on television, and you can see the resemblance, although the ghosts are in white not black. Indeed, he did see a stage ghost on television at Halloween and said: “No ears, no nose, no mouth, no eyes.” He perhaps thought he’d seen a black ghost. Imagine how surprised, excited, or even scared you would be to see a ghost in the supermarket.

The next thing to excite him greatly was, as he called him, “Johnny broken-foot,” a Paraolympian with only one foot in a dance competition on television. What he did have for a foot was a spring that was hook shaped. Alexander wanted to watch his dance again and again. He wasn’t much interested in the others, and his fascination with Johnny broken-foot continues. He’s disappointed when Johnny dances with what looks like a normal foot.

Perhaps he has never noticed disabled people, but more likely it’s the fascination of seeing a man with just a hook for a foot who can dance so well. He hopes that Johnny broken-foot will win the competition.

Johnny

 

A bad case

“Tell me, tell me, doctor

What is my condition?”

“It is, I’m afraid, my dear,

Bad, very bad.

It’s moral lunacy

One of the worst cases I’ve seen.”

“Will I live?”

“You will live magnificently

Castles, oceans, hyacinths,

Poems, stars, love,

Pomegranates, and dreams,

So many dreams.

But, and the but is big,

You will have no moral base

No rectitude, no rationality,

No religion, no beliefs.

Myself, I couldn’t bear

Such a life.

But we will help you,

We’ll send you to school

Install a moral base

Even if it kills you and us.”