Reading my diary from nearly 50 years ago, I’m tempted to make correction, revisions, and comments, but I’ve (mostly) resisted.
Up early, watermelon for breakfast, Chai comes in pots here. I am beginning to understand the magic of watermelon as in “watermelon sugar.” Make everything you need from watermelons. The morning was spent entering Afghanistan, where we arrived yesterday. First to the customs, long queue, lad in dungarees—not the overdressed officials we are used to.
“Cameras, tape recorders, televisons?”
He goes away and comes back with a remarkably smudgy stamp. OK. Away we go. A soldier stops us. Medical certificates. As we enter one of the dirtiest countries in the world we must have medical certificates approved. We’re in. More watermelon.
I asked the lad, “Where is the toilet?”
He waved around him and replied, “Everywhere toilet.” Dat’s Afghanistan.
Then we found a minibus and set off across the midday desert. Two Canadians, friends of the family, rolled two joints. Joints and dope in Afghanistan are much heavier than the usual experience. Huge chunks of very strong dope, often smoked through waterpipes. One puff of one of these waterpipes sends you reeling. I was very stoned on the dope they passed round. At the time I wrote what follows–as always a million things came into my mind but I forgot most of them.
“This afternoon I was very stoned in a minibus in the Afghan desert in the middle of the day. The heat frightened me. I saw how roads were tiny things and yet maps are all roads and our idea of country is all roads. I see Britain built on a framework of roads with many of the bits in between fallen out. I see us all holding hands and the ends of the long line holding onto an island termed ‘reality.’ I see a lot of things very clearly and know them to be right and decisions I have searched for are made in a stoned immediacy. Now they are forgotten and maybe I must get stoned again to know. And what’s good when I’m stoned ain’t good when I ain’t stoned. My teeth are white, broken polo mints and I know I’m all part of the whole thing.”
I’m not really able to cope with being this stoned, I am too much based on the illusion of being able to control my reality. I like to have my illusion, my island of reality made. When I am spaced I know I am part of it all, but at the moment I can’t cope. My body doesn’t like it either.
Herat is the first very different city we have been to. Why? Virtually everybody is dressed in Arab clothes—turbans and loose fitting trousers and shirt; there are few women and they are all in total chadors, many people are in rugs, the ‘city’ is built predominantly from ‘bricks; made with mud and straw, there are no fridges and very few Western things available. Coke, of course, but not frozen. There is an old semi-ruined city-come-fort that glowers over the city. It is not permitted to approach close—it must be some kind of holy relic. There is also an old mosque, mostly ruined with hour minarets rising up from the ruins. These can be seen from a long way out across the desert. It is very hot in Herat. A wind blows but a very hot wind. We wandered around the streets and then ate. Afghani food is not very appetising—greasy rice, potatoes, aubergines, tomatoes, a little unhealthy meat, and rather dangerous to Western stomachs so we have to eat mainly omlettes. Our diarrhoea continues.
Listening on the radio this morning to accounts of life in Afghanistan I thought back to the days I spent there in 1973, doing the “hippy trail” from London to India and back. I dug out my diary, and here is my account of our arrival.
“They called us from the garden [in Iran], and we finally set off on the bus, slowly, unsteadily, but gracefully. Soon into the desert and across the golden wastes. So much lovely emptiness. We stopped in Torbat-e-Jam. By this time there were three buses, and everybody turned out to welcome us, say hallo, tell us they spoke English, offer to sell us things, laugh at us, laugh with us. Very fine. Then up and on. Sunset over the desert. Nobody could ask for or expect much more.
We arrived at the border in total darkness, except for the big moon. The border post is in the desert. Maybe we would go through, maybe we wouldn’t. Who knows? Who cares? That’s the Asian way. We could, and we did. At the border we saw a lad sitting rather dolefully in the corner of the customs, his hand being held by a more anxious looking female. He had been caught with 100 Kilos of hash. For that it is life imprisonment or death. It made me feel very empty to see him there.
Caught with 100 kilos of hash, Iran 73
Under a desert moon
Sit in the corner
Drinking from a tin cup
And know you are caught
Caught for bringing the east west.
All that hashish
To bring desert dreams
To the Northern cities.
The crickets call
The sun throws it last gold
Over the desert
And you are caught.
100 kilos, 100 000 days
At a gram a day.
A million dreams
Is 100 000 days
And a life is 50 000 days.
You are dead for your efforts
And your eyes see death
In a desert night.
Then across non-man’s land to Afghanistan. “Allo, sir, very pleezed to see you, one Coke 15 Afghanis, very cheap, ice cold, best in all Afghanistan.” “No, I ‘ave not yacht, you are very funny.” Lad with a delightful manner in a hut that looks suspiciously as if it is in the desert. “Come in,“ he says and pulls up a chair outside the hut that nobody could possibly get in.
We stayed the night in a hotel at the border. The place and the manner of the people amused me greatly, and I was in fine form.
I’m strongly opposed to immortality, but I sometimes wonder how long I could go on learning things that I can’t believe I never knew. Perhaps for ever. I’m 70 now, and I learnt yesterday reading the introduction to Cristina Rossetti’s Selected Poems about the language of flowers. Of course, I vaguely knew that flowers carried messages—the red rose love, and a white lily the death of a child—but I didn’t realise how extensive and elaborate the language is and how the Victorians (and back as far as humanity goes) could say things with flowers that could not be said in words.
Although a great lover and reader of poetry, I realise how much I have been missing by not knowing the language. Let me illustrate with this short poem from Rossetti.
O roses for the flush of youth,
And laurel for the perfect prime;
But pluck an ivy branch for me
Grown old before my time.
O violets for the grave of youth,
And bay for those dead in their prime;
Give me the withered leaves I chose
Before in the old time.
And now with the flowers translated.
O roses for the flush of youth,
Roses are emblems of love and beauty; but here they also have with their secondary meaning of pride and danger
And laurel for the perfect prime;
Laurel is associated with Apollo, and, along with bay, symbolises poetry glory
But pluck an ivy branch for me
Ivy emblem of faith and tenacity
Grown old before my time.
O violets for the grave of youth,
Violets emblems of innocence and modesty
And bay for those dead in their prime;
Bay poetic glory
Give me the withered leaves I chose
Withered leaves symbolise melancholy and may here possibly be book leaves
Before in the old time.
What have I missed in some of my favourite Shakespeare lines:
I know a bank where the wild thyme blows,
Where oxlips and the nodding violet grows,
Quite over-canopied with luscious woodbine,
With sweet musk-roses and with eglantine.
I know a bank where the wild thyme blows,
Thyme is courage, strength
Where oxlips and the nodding violet grows,
Oxlips, cowslips, symbolise comeliness and winning grace. Their long connection to fairies also imbues an additional meaning of adventure and mischief
Quite over-canopied with luscious woodbine,
In Scotland, woodbine appears in wedding ceremonies to represent the love that clings without harming anyone. Among the French, giving woodbine (honeysuckle) to a partner represents generous love, and in China dreaming of honeysuckle means passion.
With sweet musk-roses and with eglantine:
Musk roses symbolise charm and the early stages of love (it’s a rose that comes early); and eglantine’s symbolic meaning is “I wound to heal”
You can read here about the language of flowers. https://www.almanac.com/flower-meanings-language-flowers The article includes what might be called a dictionary of the meaning of almost any flower or plant you might know, although I’ve discovered that many of the flowers in the Shakespeare passage do not appear.
The 10th revision of the International Statistical Classification of Diseases and Related Health Problems(ICD-10) has nearly 70 000 codes, suggesting that there might be that many human diseases. Diseases are inventions not realities, and much fun can be had inventing new ones—social phobia, baldness, hypotension (to counteract hypertension), female sexual dysfunction, chronic procrastination, and many more. Nobody knows how many diseases there are, but 70 000 is probably the upper limit. In the US the House Majority Leader Kevin McCarthy (R-Calif.) told Fox News in 2016 “You know, there’s 10,000 diseases, and we only have 500 cures.” Both numbers are highly uncertain, but with its round numbers the phrase sings.
Towards the end of his life Nikos Kazantzakis discovered Buddhism and began to practise total renunciation. In Vienna he met an attractive woman at the theatre, and they left together and stayed up talking until late. Kazantzakis invited her to his room, and she said she would come the following evening.
When Kazantzakis woke on the morning of their assignation his face had bloated and his lips swollen. He wrote to the woman and suggested she come the next day, but his condition worsened, and his lower lip began to run with a yellow liquid. The assignation was cancelled.
The condition persisted, and a man who turned out to be Wilhelm Stekel, a psychiatrist, saw his condition and offered help. When Kazantzakis told Stekel the story of the woman, Stekel with joy diagnosed Saint’s disease, which was common in the Middle Ages but was now almost unknown.
The disease manifested itself when the desert ascetics of the Middle Ages could no longer resist the temptations of sex. They would walk towards cities seeking sexual satisfaction, but as they progressed “their bodies would break out in horrible running sores, the faces became bloated, and a yellow liquid dropped from the sores.” The cause was, Stekel said, “subconscious resistance to sin (which the saints supposed to be a punishment from God).”
Kazantzakis had for years been pursuing “total asceticism,” leading him to leave his wife. As soon as Kazantzakis left Vienna, the sores disappeared.
Saint’s Disease has presumably largely disappeared because “total asceticism” has gone out of fashion in our consumerist age. Perhaps it is commoner in India and other places here asceticism is more valued.
In his magnificent memoir, which our son copied out and I never tire of reading, Syd, our father (I always write “our” because I have two brothers, but it makes our father sound like God), wrote: “Captain Burn was writing a book related to Colditz and asked me to do a copy of it so that, should the Germans find it, there would be another. I was supposed to have been paid for this but never was. It was only years later that I discovered a copy of it in a café on top of Shakespeare Cliff in Dover. I paid 6d for it.” Our father doesn’t say if he read that copy, but I have now read the novel, which is called Yes, Farewell, a title taken from Dostoevsky’s The House of the Dead.
I met Michael Burn years later when he visited Syd. I didn’t pay much attention, but I wish I had as was a remarkable man. Burn, known usually as Micky Burn, was a journalist, commando, writer, and poet. Born in 1912 into an upper middle-class family, he attended Winchester College and then Oxford, which he left after a year to begin a career as a writer. A bisexual he “befriended” Alice Keppel, the former mistress of Edward VII, in Florence and later had an affair with Guy Burgess, the spy. Wikipedia says that twice “during the 1930s Burn took himself to the police to avoid being blackmailed for the crime of homosexual conduct.” (I wonder how he avoided being charged himself.)
Burn writes in his autobiography that he “had been drawn to three autocracies: German National Socialism, Communism, and the Roman Catholic Church.” Burn met Hitler, who signed his copy of Mein Kampf, and stood behind the Fuhrer at one of the Nuremberg rallies.
After joining The Times in 1936, Burn abandoned National Socialism and joined the army when war broke out. Volunteering to accept exceptional risks, he became a commando and took part in the St Nazaire Raid leading a troop of 29 men. Fourteen were killed, and the rest captured. Burn was awarded the Military Cross and eventually arrived in Colditz. While there he received parcels from the Dutch Baroness Ella van Heemstra, and after the war he returned the compliment, thereby possibly saving the life of Audrey Hepburn, the daughter of Heemstra. Burn also ran communist meetings with Giles Romilly, the nephew of Winston Churchill. Syd attended these meetings.
After the war Burn served as The Times correspondents in Moscow and later Hungary, wrote nine books of non-fiction, four novels, six books of poetry, and a play. Married to Mary Booker in 1947, he lived in North Wales next to Bertrand Russell, who became a friend. After his wife died in 1974, Burn found her love letters to Richard Hillary, a pilot killed in the war, and wrote a book about their affair. He died aged 97 in 2010, six years after Syd.
Burn wrote his novel while in Colditz, and it was published in 1946. The plot is simple, beginning with an account of life in Colditz. Alan (Burn) escapes with two others and travels across Germany towards Switzerland. They are captured just before reaching the border and put into a political prison in Munich that is much grimmer than Colditz. There they meet Dr Tomavich, a historian, and great discussions are held about fascism and socialism. A theme is how the war was much harder for those on continental Europe than those in Britain. Alan’s friend is killed (the other had gone his own way and did get to Switzerland), but he is returned to Colditz, where he awaits liberation. The novel ends with the quote from Dostoevsky:
Liberty! New life! Resurrection from the dead!
It was the descriptions of Colditz that interested me the most. Burns writes: “At least fifty novels had been started in the castle; they were like tunnels, means of escapes, usually ending half-way through.” Burns did well to complete a novel of 432 pages (some 160 000 words), and Syd must have worked hard to copy it out. Once when hitchhiking, I was picked up by an air force officer who had also been in a German prisoner of war camp, and he said that it was one of the best times of his life, “like a university without women.” And Burns writes: “A prison, with books and young and civilised companions, could be an excellent place in which to collect one’s thoughts before emerging into the distraction of peace.”
The prison, like Britain, was stratified by class. Alan was a prominente, an officer, upper class, and important prisoner—as was Romilly, Earl Haig, and Douglas Bader. Syd, in contrast, was a soldier, an orderly. Alan befriended the orderlies and was somewhat jealous of their freer life: “These soldiers lived in a separate part of the castle. They were the only prisoners allowed outside. They went to fetch rations and parcels and they looked healthier than the officers, most of whom had lost their muscles. They had girls in the village.” Alan is criticised for fraternising with the orderlies: “They say you’ve taken to hobnobbing with the orderlies…I suppose you’re cultivating the common touch. The people are delightfully simple, aren’t they.” Burns is mocking not approving this gross snobbery.
Burns observes that the orderlies “had come from working parties and stalags and had seen a good deal which the officers had not seen in the mines and on the farms.” Syd had worked down the mines before being sent to Colditz. One orderly, Fell, says to Alan: “Where we was they sent us to the mines. That was ten hours a day and no parcels, most of the time.” I wondered if Fell was partly based on Syd. Fell performs at one of the many plays put on in the castle: “Fell was lurching about trying to sing. He was dressed as a witch-doctor, with ping pong balks for eyes.” We have a picture of Syd dressed in an extraordinary way.
Together with another orderly, Fell distilled hooch in the rafters in the soldier’s quarters. “They sold it to the officers and were keeping back several score of bottles to sell at a higher price later, after the invasion. They had made several hundred pounds already and they still had thirty-five bottles left.” Syd doesn’t mention distilling hooch, but he does describe Earl Haig drunk on “hooch.”
After liberation “The soldiers had come own from the castle and are laughing with the girls. Fell had one of the prettiest.” Syd always had a way with women and describes spending a “few ecstatic hours” in the “embrace” of a Polish girl after liberation.
Young men locked up in a castle with nothing much to do inevitably thought about sex, and a theme in both Burns’s novel and Syd’s memoir is how the men fancied some of the men who dressed up as women for the plays. Burns writes: “There was a theatre in the castle which had once been used by the lunatics and plays were put on whenever the Germans allowed. Tony Masterman played all the feminine leads. He was twenty-two, a naval lieutenant with a pretty face, pink and white cheeks and fair hair….He had many admirers and there had been curious jealousies and sulks about him, and one or two fights.” Later the novel suggests that Masterman was providing “a public service.”
In his memoir, in Konigstein Castle rather than Colditz, Syd writes about Ginger Storey: “As time went by, we all began to regain our strength a little. No work and slightly better food helped. Our sexual feelings began to return. I’d never had any homosexual feelings, but I noticed that I began to fancy Ginger Storey– but I also noticed so did everybody else. Ginger was a little bloke and quite ugly but seemed to have some femininity. Nobody put their feelings into practice as far as I know.” Syd did write about his sexual experiences with women, but I doubt that, despite the honesty of his memoir, he would have described a homosexual experience. Burns was bisexual, but the obscenity laws would have stopped him being more explicit in his novel.
I felt connected to our father, who died in 2004, as I read the novel that described his life in Colditz, in which he may feature, and that he’d copied out while a prisoner. We were privileged to have such a warm and human father.
I took many quotes from the book:
Life in Colditz
Once they had been individuals but the castle had got the better of the. It drained them like a leech, until nearly all subsided into a grey neutrality.
Because they risked sliding into a negative attitude towards life, it became important to have something to do.
All the prisoners had changed in appearance. Those vertical lines of strain had come between their eyes. Their eyes lacked lustre, their hair had gone dry and in places grey, and most of them had pale and lifeless expressions.
They would linger over the slightest pleasures, counting all their blessings.
Cynicism was the castle’s dominant mood.
Three gramophones blare out symphonies.
They could not help it. They had become fussy and carping, worried about small details excessively, and unable to fling their imagination across the wire. This had been happening to him, and that was why he had to get away.
In the castle people asked questions to have an excuse for talking themselves. There was little exchange, Parallel monologues, Larkin had called them
Your castle is not for the really dangerous ones.
The castle with its books and parcels and visits from the Red Cross.
Jim’s got ennui. Everyone gets it here. You can’t help it. I’ve had it often. Rather badly at one time. If you think at all, you’re bound to get it. It’s the degout de la vie.
The Germans, Poles, Dutch, Russians, etc. Funnyish. P 287.
Dark figures distilled it [hooch] under the rafters among big containers and long pipes. (Potcheen)
Alan wanting to go to the orderlies’ drinking party. P305.
Liking the orderlies. P316
Account of Tony p 354-5. Men dressed as women, some garish but Tony highly desirable. “a kind of public service.”
He had been so long without the plain unconfined life that its details were ten times more to be enjoyed now that he had them within reach. He would for a long while to come, perhaps for life, notice everything more keenly and find it easier to be absorbed away from himself.
The first fresh milk he had seen for three years.
The prison in Munich
We do not know why we are brought here, or how long most of us will stay here, or why we leave here.
What a relief it was [to hear the story of Dr Tomavich]. Like a new lease of life, like the door being thrown open. The cloud of terror which hung over the world all around them scattered and the table they sat at became a patch of freedom.
It is part of the human endeavour to create and to be free. It springs from something more enduring than a nation.
The nazis wanted to degrade and cow us and so they made us do work in which there was no point. We worked ten and 12 hours a day, digging trenches which later we filled in again.
You are more observing. You are observing and absorbing all the time.
New and old prisoners
They had a victory mood which was quite strange to him. New prisoners who came to the castle from the fighting in Italy had it too.They were different from the prisoners from of Dunkirk and Norway. Their brown, cheerful faces showed up, and their voices were cheerful and animated. They had none of the older prisoners’ desiccated cynicism.
Discussions, lectures, arguments in the prison
Discussions, books in all languages, cards, lectures on agriculture, sport, different people’s jobs, technical subjects, business training. (p199)
We should build up a picture of a new England, of a new Europe, of a new world. We should have many arguments. I am accustomed to such arguments.
Britain v Europe suffering. P 203
The people everywhere have always been in a state of famine. At intervals they are without food of any kind. At all times they have been starved of a full life.
Morshead’s meetings. The ones Syd attended. P315.
Man and nature
The real task was to extract the riches of nature…what was needed was to enlarge the total income, and that could be done by drawing out the power hidden in and under the earth, in the sea, and in the air, and harnessing it to serve us.
Bringing the full force of human beings into the struggle with nature, which is our real task, instead of against one another.
Life in the castle as liberation comes closer plus an account of the hidden radio. P275
The room was terribly bare, terribly ugly. Nothing was neat or comfortable or soft or yielding, and he wished that he could dream again and go on dreaming until the war ended.
It was a question of who would liberate them; the Russians from the east, or the Americans or British from the west.
The war had given men back their fellowship in order to confront ther death. He wanted the same kind of fellowship in order to confront life.
The dreaded days of their captivity had returned, and the end was worse than the beginning….little food…the temperature stayed steadily below zero….p 390
He was left with an overwhelming memory of animals, obsessed with trivialities, enslaved by their bellies, unable to trust one another. Calm voices became querulous, querulous vices shrill.
Jim talking about women and about love. He made them live for Alan as Tomavich had made history live, and Morshead had made the politics and economics, and Count Eulenstein had made his great world of the past, and Fisher his own ambitions and struggle.
The most passionate longing for life, and for living people, and the living world, and to work with them and for them, welled up in him. And at last he could say aloud the words he had been waiting so long to say, Dostoevski’s words of liberation, gratitude, and hope,
“In the middle of the main room, on a bier, was the corpse of the master of the house, laid out for the funeral ceremony. It had been washed with wine and veiled in a linen shroud. A cross of wax lay upon the lips, and a small ikon of the Redeemer had been placed in the crossed hands. Two huge lamps were burning, one at the feet, the other at the head. His eyes had remained open and were glazed: since no one had been there to close their lids when they were still warm, they would not shut.”
This description comes from Freedom and Death by Nikos Kazantzakis, and the corpse is that of Manύsakas, who has been killed by a Turkish bey. The country was Crete, and the time was the end of the 19th century when the Ottomans controlled Crete. Manύsakas had insulted the Turks by carrying an ass on his shoulders into the mosque.
The night of mourning begins with the women keening over the corpse. (Keening, the universal response of women to a death, has gone out of fashion, but I remember hearing it in Africa when I was a medical student.)
By midnight only three bosom-friends remain: Fanύrios, brother of Manύsakas and “the man of the grasslands”; Stratés, godson of Manύsakas and “a sturdy young man of thirty-five, of healthy stock, with a pointed beard, slender hips, and an open forehead”; and Patasmos, “the lyre player.”
The three men and the corpse had in previous days “emptied whole casks of wine together [and] devoured whole sheep to the bones. Patasmos looks at the corpse and says “Yes, a man’s no more than a bladder—it swells and swells and suddenly—poof—it bursts and goes to the Devil…I men to paradise.
Fanύrios “feels his innards grown tense with hunger…’Chaps, what do you think? My eye caught sight of some strings of sausages and a demijohn of raki in the cellar. Shall we drink to his salvation?’
Worried that the women may detect the smell of cooking, they shut the doors, roast the sausages, pour the raki, and go the cellar for a loaf of bread. “They gripped their glasses, and touched fingers to avoid the clink.”
“God bless his soul, said Fanύrios.
His health, chaps. Ours too,’ cried Patasmos.
‘Drink it all in one gulp,’ said Fanύrios, ‘The demijohn, God has sent it to us—is half full. Brother Manύsakas. Fare well.’”
They eat the sausages with bread and find white cheeses as well. They toast the widow, Manύsakas’s brother, and “all the people we know…whether they’re alive or dead.” That was a lot of people. They become very drunk.
After weeping over the corpse, Fanύrios says: “‘Chaps…shall we jump over him? They pulled their sagging breeches-ends well up, so that their legs should be unencumbered, seized hold of the bier and placed the corpse in the door to the yard, so as to give room for a run.”
Fanύrios, as the brother of the dead man, goes first. “He took up a position by the street door, spat on his hands, took a run, and let fly. His skull hit the lintel with a crack, but Fanύrios did not notice, and landed on his feet in the middle of the room.”
“Stratés too took a run and with his supple, slender body sprang in a low arc without touching the corpse. He landed lightly on the tips of his toes.”
Patasmos, the lyre player, was more nervous. His “heart flinched. He gazed at the bier. How the Devil can one jump so high?” He decided that he would not jump.
“Aren’t you ashamed of yourself…are you a Cretan or mainlander?” asked Fanύrios. It’s an insult…Jump, even if you fall down dead.
Patasmos remembered how much he loved Manύsakas. “His sense of honour awoke.
He took the run and got up speed. But as he came to the dead man, it seemed to him that their bier reached up to the ceiling. His legs caught the front of the bier, the impetus was communicated to the corpse, and it rolled to the ground—Patasmos, with hair all over the place, beyond it.
They lift up the corpse. “There, brother, you’re dead. It doesn’t do you any harm. It hasn’t hurt you.”
The death of a child is for most parents the worst thing that could happen to them. It is against the natural order for the child to die before the parents. But could it be that children are more accepting of death than adults?
In Waiting for the Last Bus: Reflections on Life and Death, Richard Holloway, former Bishop of Edinburgh, describes his debate with Richard Dawkins, the “militant atheist,” in which he asks Dawkins what he would say to a dying child. Holloway, the most bookish of priests, quoted from The Last of the Just, by André Schwarz-Bart, a novel about the Holocaust. A child asks what death will be like, and an adult tells him it will be like a dream. A woman criticises the man for not being truthful, and he responds, ‘Madame, there is no room for truth here.’ Holloway says that this must be the case for dying children, telling them perhaps that they will be in Heaven and see again all those that they love. He challenges Dawkins about what he would say, and Dawkins answers “the same.”
Holloway, who has spoken with dying children, concludes: “It turns out that there are times when it is impossible to accept the utter finality of death. A child’s death is one of them. There is no room for truth here. There is only room for the impossible act of consolation.”
But M R Rajagopal (known to all as Raj), the internationally-acclaimed palliative care physician who has spoken with many dying children, would disagree. In his book Walk with the Weary: Lessons in humanity in health care (which I have already written about https://richardswsmith.wordpress.com/2022/07/23/a-prescription-from-kerala-for-transforming-medicine/) he writes: “Paradoxically, children seem to accept incurability or death much more easily than adults….Children have amazing resilience. In my experience, they can process bad news much more easily than adults.”
Raj tells the story of Joseph, a dying child, who asked his mother “Will I die before you?” Hs mother couldn’t answer but asked Raj to talk to him. Raj and his team had realised that dying children usually knew that they were dying even though their parents had not told them and that they had many irrational fears about death that could be dispelled. Joseph was worried that he would suffocate when he was buried. Raj told him that there was no discomfort once somebody was dead. Raj asked if he had any other questions, but Joseph said no and went to play on his computer.
“Children,” writes Raj, “have short attention spans. They don’t want lectures; they ask straight questions and want straight answers. That is enough to reassure them. They need to be given the opportunity to ask those intense, and at times profound, questions. Without honest answers, their misery and loneliness cannot be imagined by you or me.”
Eight-year-old Abdul, for example, was worried that God would punish him when he died because had had pulled his sister’s hair and once stolen her pen. Raj consulted with the religious authorities who said that wrongs committed by children under 15 were not punished. Abdul could be reassured. (I found myself wondering what Raj would have said to a 16-year-old.)
Raj also tells the story 11-year-old Thasleena, who “taught us more than most, about love, endurance, courage, hope and above all, the fragility of life.” She had a large tumour in her leg that gave her severe pain and had metastasised to her lungs. Her doctors had advised amputation. Thasleena didn’t want to be “half a person” and refused. Raj talked with her and encouraged her to see a popular film that had a hero with one leg. After watching the film she agreed to an amputation.
After the amputation she had some months of pain-free life, and she it was who cut the ribbon to open the new palliative care unit. But her cancer returned, and she died. Raj concludes: “This 11-year-old ‘guru’ taught us lessons in resilience, acceptance, and endurance. She taught us how one can enjoy life even when in pain and with death staring in the face.”
There are few things in life more difficult than to talk honestly about death with a dying child, and the conversation may be avoided not for the benefit of the child but for the benefit of the adult.
Competing interest: RS and M R Rajagopal worked together on the Lancet Commission on the Value of Death.
BBC Radio has had a wonderful series called Conversations From a Long Marriage written by Jan Etherington in which Roger Allam and Joanna Lumley who have been married “for ever” have conversations that are ridiculous, often funny, and very familiar to people like my wife and me who have been married for close to fifty years.https://www.bbc.co.uk/sounds/brand/m000dpqn We have similar, if not such artful, conversations. Here’s one we had this morning.
Wife: How did you get that brown stain on your shirt?
Me: I was eating a chocolate covered lolly?
Wife: Why can’t you eat without getting covered in food?
Me: Eating the lolly was tricky. Almost everybody would have got chocolate on them.
Wife: It’s the way you do everything. You throw your food into your mouth from a distance and often miss. You blow your nose, holding the hankie inches away from your nose and blowing your snot into it.
Me: I’ve got a great idea. When you give the eulogy at my funeral you should list all my disgusting habits. That would be much more interesting than an enumeration of my virtues, especially as there are so few of them. It would make a change from the usual funeral. Shake up the form. Perhaps set a new trend.
Women framed in windows is an artistic subject particularly associated with the Dutch Golden Period. Rembrandt’s Girl at a Window, which is owned by the Dulwich Picture Gallery, is the classic example and presumably was the initial inspiration for the gallery’s exhibition Reframed: The Woman in the Window. The exhibition shows how the subject is ancient and how, although all the original creations were by men, woman have adopted the subject and freed themselves.
As I toured the exhibition, I had in my head the already iconic picture of Chloe Kelly celebrating after scoring the winning goal in the final of the European Football Championships. The picture shows joy, exultation, and freedom, whereas most of the pictures in the exhibition show women enclosed, unfree, there to be gazed at by men. The classical pictures often include a bird’s cage, symbolising the kept nature of women, and domestic objects, illustrating women’s role.
The first exhibit was perhaps the one that will stay in my head the longest, a small Greek sculpture from almost 3000 years ago of a woman, probably “a sacred courtesan,” looking from a window.
As well as the somewhat sad sculpture, there was a funny picture on a Greek (or was it Roman?) vase of a lustful probably drunk man with bare legs and white shoes climbing a ladder to reach a woman looking from a window. The man is being helped in his quest by what looks like a bearded man in drag, wearing a short white dress and holding a flare.
Even more powerful than the Greek sculpture was a 15th century sculpture hacked from a church of the head of Saint Avia locked into a cell for refusing to marry. People fed her through the bars.
The best pictures in the exhibition in addition to the Rembrandt were Botticelli’s wistful portrait of Smerelda Bandinelli and Picasso’s aggressive painting of his mistress Marie Françoise Gilot, whom he abused, just before their separation. The Botticelli seemed to be painted with love but the Picasso with hate.
I am now realising with horror that none of the pictures I’ve selected from the exhibition was by a woman, but even some of the pictures by men were “fighting back,” depicting women more like Chloe Kelly than the sacred courtesan locked in a Greek temple.
Wolfgang Tillman’s large photograph of DJ Smoking Jo shows a woman full of confidence looking out on the world.
Tom Hunter’s photograph of a woman in a squat in East London is closely modelled on a Dutch painting and shows a woman unafraid of an eviction notice. The eviction notice is framed beside the photo.
Windows took on a great significance in the pandemic, allowing a barrier that the virus couldn’t cross but people could look through to the people they loved. Simran Janjua’s photo shows a grandmother and granddaughter meeting through glass. The grandmother is probably contained in a nursing home, but the granddaughter is free. The exhibition could have included a woman looking through the “window” of an Ipad at her husband dying in intensive care.
Dreams have content but no meaning, like life. We have responded by creating myriad religions, and millions of theologians have spent lifetimes squeezing meaning from those religions. I can do the same with my dream.
My dream seemed to happen within a royal college, which is not surprising as because I’m the chair of the UK Health Alliance on Climate Change, an alliance of royal colleges and others, I spend much time thinking about colleges.
In this composite college I met Gordon Brown, the former prime minister. With a wide grin, he slapped me on the back and said “I call you Britain’s Chief Value Officer.”
“We do,” I responded, “need less attention to cost and more to value.”
I was a student in Edinburgh at the same time as Brown and knew him slightly. I bumped into him over the years and met him last year at COP26 in Glasgow. Somebody took our photo, and the picture shows us both with wide smiles. We don’t have chief value officers in Britain, but I have a friend in the US who was the chief value officer of a large health system.
Value, you remember, is benefit divided by cost. You can increase value by producing more benefit for a unit of cost or by producing the same amount of benefit for a lower cost.
I have been thinking about value in health care, particularly about value at the end of life. As the Lancet Commission on the Value of Death (which I cochaired) found, something like 10% of annual health expenditure goes on the 1% of people who die in that year. Most of the money is spent in the last few days and weeks of people’s lives, much of it on hospital care including intensive care. Is that value for money?
For the dying people it might be. Perhaps the treatment extends their lives, and we know that people will pay a great deal for extra weeks of life. As Shakespeare writes in Measure for Measure:
“The weariest and most loathed worldly life
That age, ache, penury, and imprisonment
Can lay on nature is a paradise
To what we fear of death.”
Perhaps the treatment keeps the people comfortable at the end of life, allowing them to die with dignity, but we know that families, friends, and morphine can keep people comfortable at minimal cost. The treatment must be active treatment, including surgery and time in intensive care. We know that there is much overtreatment at the end of life, and that treatment probably increases suffering, although suffering is hard to measure—as are love, freedom, and most of what makes life worthwhile.
As Britain’s Chief Value Officer, I would have to advise the Prime Minister that it’s hard to reach a confident conclusion on the value to the individual of the high expenditure at the end of life. But if asked to use my judgement I would say that despite Shakespeare it’s poor value for the individual.
But when it comes to society that huge expenditure is poor value, particularly when health care is crowding out expenditure on education, housing, benefits, the environment, transport, the justice system, and the arts, most of which are more important for health than health care. To deny a child good food so that a dying person, usually old and often very old (over 80), can die in intensive care is not value for society.
I would advise the Prime Minister that high expenditure at the end of life is poor value for society. “How,” he would ask me, “can I balance the value to the individual against the value for society?”
“That,” I would answer, “is the job of politicians.” “But,” I might add, “you could ask people’s opinion with some sophisticated questions. You could also say that all NHS treatment will continue to be free at the point of delivery until a particular age, perhaps 75, and that palliative care will be free at all ages but if people want intensive treatment after 75 they will have to take out an insurance policy before the age of, say, 40. My guess is that few people will. I recognise that this would break fundamental NHS principles, and there would have to be a means test for the insurance premium. I wouldn’t, however, advise making it free for the poorest because my judgement is that we would be giving them the opportunity to suffer more.”
Back to my dream. The other part of my dream was murky, but it revolved around the discovery that unbeknownst to the senior leaders of the college the staff were having to live off either horsemeat that was past it’s sell by date or food intended for animals.
What might this mean? I passed yesterday in Sainsbury’s the box of food intended for the food bank. It was fuller than ever. Many people in Britain, including children, are going to bed hungry—as are about a billion people in the world. Was my dream telling me that it makes no sense to spend so much on health care, particularly on intensive treatments for the dying, when children are going hungry. Was the dream also telling me that the country’s leaders simply don’t know—in a deep sense of know—that so many are hungry.
Or could this be a message about NHS staff being fed horsemeat, being exploited? Bearing in mind that expenditure means activity and that about three quarters of the spend on health care is on staff, the high spend at the end of life means that staff are spending lots of time treating—and probably overtreating—people at the end of life. Their time and energy could be better spent. As it is, NHS staff are like hamsters in a wheel, having to run faster and faster to keep the show on the road. It’s not sustainable.
My conclusion: dreams have content but no meaning but hours of fun can be spent trying to give them meaning.