How Sofia opened Robert Conquest's Eyes

Robert Conquest – who died last month at the age of 98 – was the best known British investigator in the post-war period of the true scale of the communist tyranny.  During the 1960s he edited eight volumes of work including “Common Sense About Russia” (1960), “The Soviet Deportation of Nationalities” (1960) and “Power and Policy in the USSR” (1961). His other early works on the Soviet Union included “Courage of Genius: The Pasternak Affair” (1961) and “Russia After Khrushchev” (1965) published in the United States republished as The Contemporary Soviet Union Series by Frederick Praeger, whose U.S. company published, in addition to works by Aleksandr Solzhenitsyn, Milovan Đilas and a number of books on communism.

Many of us saw him overly fixated on Soviet atrocities - but the opening of soviet records after 1990 proved him correct. 

I learned several new things from the obituaries and tributes of recent weeks. First that he was a poet and close friend of Kingsley Amis – with a strong line in doggerel.  

But the most important insight was that his revulsion against Soviet tyranny stemmed from his personally witnessing the Communist takeover of Bulgaria in 1944 – an event which I have written about here. In 1944, Conquest was posted to Bulgaria as a liaison officer to the Bulgarian forces fighting under Soviet command, attached to the Third Ukrainian Front, and then to the Allied Control Commission. There, he met Tatiana Mihailova, who later became his second wife. At the end of the war, he joined the Foreign Office, returning to the British Legation in Sofia. Witnessing first-hand the communist takeover in Bulgaria, he became completely disillusioned with communist ideas. He left Bulgaria in 1948, helping Tatiana escape the new regime. Back in London, he divorced his first wife and married Tatiana.

The third fascinating fact is that, on the war’s end, he actually joined the Labour Party’s International Bureau – working therefore with Dennis Healey (who sadly died about 10 days after I drafted this - at the ripe old age of 98). Conquest then joined the Foreign Office's Information Research Department (IRD), a unit created by the Labour government to "collect and summarize reliable information about Soviet and communist misdoings, to disseminate it to friendly journalists, politicians, and trade unionists, and to support, financially and otherwise, anticommunist publications."

You can read more about his life here. He is an obvious candidate for the next entry in the blog Britain is no country for old men

Carbon Democracy

Those of us who try to keep up with things have piles of books on the key subjects of the day - "global warming", "end of oil", "neoliberalism" or "Islamic extremism". The books in each of these categories all have their particular cast of characters; storyline; prescriptions; and prejudices. But, like ships that pass in the night, they steer clear of (and rarely reference) one another. 

I’ve just finished a rare book which aims to connect the dots between these categories – it’s Carbon Democracy – political power in the age of oil (2013) and a stunning bit of work whose provocative historical insights turn upside down many of our preconceptions 

The use of coal and oil in the context of industrialization has always been about who has the power to profit from the surplus these energy forms produce, but until now, no one has pulled the various historical details together into a historical narrative laying bare the fascinating power dynamics behind the rise of Western political systems and their relationship with energy. Carbon Democracy is an examination of our civilization’s 400 hundred year use of carbon-based energy fueling sources, and the political systems that grew up intertwined with them. Rather than presenting energy and democracy as separate things, like a battery and a device, Mitchell discusses the political architecture of the Western world and the developing world as inherently tied to fuelling sources.

The thesis is that elites have always sought to maximize not the amount of energy they could extract and use, but the profit stream from those energy sources. They struggled to ensure they would be able to burn carbon and profit, without having to rely on the people who extract and burned it for them. Carbon-based fuels thus cannot be understood except in the context of labour, imperialism and democracy. 

This book is a response to David Yergen’s The Prize: The Epic Question for Oil, Money, and Power, a classic story of hardy entrepreneurs taking huge risks to find oil in the most remote places. Yergen’s narrative centers on oil scarcity, and its contributions to economic growth in a capitalist framework. Oil is, to Yergen, the prize, solving the key problem of how to supply enough energy for a modern consumer society with a flexible and inexpensive fuel source. 

In Carbon Democracy, Mitchell has a counterintuitive take on oil, one that after a while, makes much more sense than Yergen’s. Mitchell points out that the problem of oil has never, until recently, been that it is a scarce commodity, but that it is a surplus commodity. We had too much of it. And the central problem that this created was now how to find more of it, but how to ensure that oil cartels profiting from high oil prices could make sure that very few new oil finds, especially from the massive fields in the Middle East, came online.

Far from a hardy band of entrepreneurs searching for more oil, the story of oil is one of parasitic cartels manipulating governments and inventing concepts like mandates, self-determination, and national security to ensure they could retain high profits selling a widely available commodity. But Mitchell takes the story much deeper than Yergen did, because Yergen’s book is fundamentally a fairy tale that skirts over questions of labor and colonialism. 

Mitchell goes back before the widespread use of oil, to the industrialization of England and England’s use of carbon-based fuels, like forests, peat, and coal. Industrialization demanded two seemingly contradictory factors – huge new tracts of land to grow industrial raw materials like cotton and high energy food crops like sugar, and far more centralized urban centres for manufacturing. What happened, of course, is that England simply acquired colonies with large land tracts overseas, using slave labour to harvest necessary commodities, while becoming an urban society in its core areas. Eventually, England began using coal to fuel its economy, leading to substantial economic growth and imperial strength.

Coal, though, presented a challenge to the governing elites, since the characteristics of coal, with its labour intensive extraction methods, were quite vulnerable to strikes. Coal was hard to transport, and miners operated underground in a collaborative manner. Once on the surface, coal had to be moved by fixed networks of trains. There were multiple bottlenecks here, and in the late 19th century, for the first time, the energy system of the industrialized world was reliant on workers who could withhold their labour and block a key resource. This translated directly into political power. 

As Mitchell put it, “Coal miners played a leading role in contesting work regimes and the private powers of employers in the labour activism and political mobilisation of the 1880s and onward. Between 1881 and 1905, coal miners in the United States went on strike at a rate of about three times the average for workers in all major industries, and at double the rate of the next-highest industry, tobacco manufacturing.” The coal industry was the key radicalizing force in bringing democracy to the Western world…….

Mitchell is a British born political scientist and student of the Arab world. He is a professor of Middle Eastern Studies at Columbia University having previously been Professor of Politics at New York University. When he arrived in the United States in 1977 to start a Ph.D. in Politics at Princeton, he was 

"surprised to discover that the Politics Department at Princeton was teaching the same old positivism. I was interested in the politics of the Arab world, having traveled there several times, so I evaded political science by taking courses in Middle Eastern history and Arabic language and spent three of the next six years studying and researching in Cairo”. 

He’s also the author of Rule of Experts – Egypt, technopolitics, modernity (2002) and it’s this background which helps give his study of “Carbon Democracy” such great originality…The book has an amazing historical sweep but gives us chapter and verse on aspects of the various turning points of the developments of coal and oil in Britain and America which tend to remain hidden from view in most accounts….. And what a wonderful title - "carbon democracy", with all its connotations of institutional aping...The excerpts are from the long review the blogsite “Naked Capitalism” gave the book in 2012 

Flowing through the narrative is the question of imperialism and neo-imperialism. A variety of ideological mechanisms, such as the self-determination ostensibly preached by Woodrow Wilson, were in fact ways for Western oil consuming states to control and slow the flow of oil from poorer but oil rich countries.
Mitchell shows how Palestinian strikes at oil installations in the late 1930s led Britain to support a Jewish state in the area, and how American mining engineers helped craft the apartheid regime in South Africa.

 At the same time, aggressive left-wing parties in the British parliament sought to combat imperialism, because they understood that imperialism abroad was meant to break the power of British labor – in particular coal mining – at home. Mitchell pays particular attention to the negotiations of the Treaty of Versailles and the period of negotiations after World War II to set up an international management framework. The League of Nations, he writes, “was to be an economic mechanism to replace, not war between states, but its taproot – the conflict over material resources.”

In addition to what would become the World Bank and IMF, Keynes wanted to establish an international body to manage commodities, including and especially oil. While no institution was ever set up to do this, a framework of national security and “the Cold War” managed to keep Middle Eastern and Russian offline for a long period of time. In addition, the oil companies used public relations to encourage a high oil consumption lifestyle in the United States, so as to keep the price of oil as high as possible. In Europe, Mitchell encourages a revised view of the Marshall plan, as a joint European and American elite plan to break European labor power. It’s a particularly interesting way to interpret the rise of the European Union, one deeply at odds with thinkers like George Soros who see the EU as a success of far sighted visionaries who sought to to build an “open society”.

Mitchell cites American intervention in post-WWII European economic and political arrangements as evidence. Three years later, after rapid inflation caused real wages to collapse, coal miners joined a series of strikes demanding that the government increase pay levels or extend food rations… Rather than yield to these claims, France and other European governments turned to the United States. Keen to promote their new corporate management model abroad (and to have Washington subsidise their exports), American industrialists used a fear of the popularity of Communist parties in Western Europe to win support for postwar aid to Europe. ‘The Communists are rendering us a great service’, commented the future French prime minister Pierre Mendès-France. ‘Because we have a “Communist danger” the Americans are making a tremendous effort to help us….

The European Coal and Steel Community, established as a first step towards the political union of Europe, reduced competition in the coal industry and supported the mechanisation of production, with funds provided to alleviate the effects of the resulting pit closures and unemployment. The United States helped finance the programme, which reduced the ability of coal miners to carry out effective strikes by rapidly reducing their numbers and facilitating the supply of coal across national borders. The third element was the most extensive. The US funded initiatives to convert Europe’s energy system from one based largely on coal to one increasingly dependent on oil.

The curious thing, however, for a book with “democracy” in its title, written by a political scientist and with a sub-title which includes the phrase “political power” is how little exploration we get of the implications of the end of oil for our so-called democracy. The book is very strong on the methods used to “manufacture” the “consensus” of the ruled (curiously without mentioned Chomsky!!) 

"Send these, the homeless, tempest-tossed to me"??

Austerity policies and anti-terrorism strategies have become two of the strongest parts of European government responses to the global crisis which has gripped the 21^st century……precisely the conditions for stoking up public fears about the wave of refugees pounding European borders.

The shocking scenes which hit us earlier in the year from the Mediterranean and now from the Balkans show a crisis, we are told, as great as any in the post-war period. Figures become meaningless after a time – so what are we to make of the figure of 50 million “forced refugees” – quickly taken up to 60 and then 70 million?? This report is a useful guide to the problem.

 Before any comment, let’s remind ourselves of some previous “flows”…..

·         Armenians were brutally evicted from their lands by the Turks after accusations that they had been helping the (Russian) enemy – the famous travel writer, Leigh Fermour, paints a vivid picture in his final book of meeting up with some of their descendants in the early 1930s in Plovdiv in central Bulgaria (as I did 75 years later).

·         Greek aggression led in the early 1920s to savage ethnic cleansing and population exchange between Turkey and Greece;

·         Italians bled from the country in the early part of the 20th century – whether to the US or my hometown in Scotland

·         Hitler’s persecution of Jews in the 1930s led to a massive exodus from which America and Britain were the beneficiaries;

·         no quarter was given during the murderous Spanish civil war and led to a huge refugee flow across mountains to southern France.

·         The end of the war – and the radical redrawing of European boundaries by the victorious forces – saw tens of millions of people forcibly removed from their homes and trekking in all directions. Keith Lowe’s 2012 Savage Continent; Europe in the aftermath of World War II rightly talks of it being “an until now unacknowledged time of lawlessness and terror” to whose portrayal the final section of Stephen A’Barrow’s recent Death of a Nation added a powerful voice.   

·         Post war saw the first ships arrive in Britain with West Indians seeking a better life – joining Indian and Pakistan middle class people whose restaurants woke the country up from a gastronomic torpor…

·         and Germany was, of course, the recipient of many Turks in the 1970s also seeking a better life there….

In 1975 John Berger wrote a book called The Seventh Man - one in seven of the working force in Britain and Europe was then an immigrant. And indeed – full disclosure - so am I! My blog masthead states, rather cheekily, that I am “a political refugee from Thatcher’s Britain” but I am actually more of an economic refugee. It’s the fees I earned from my work with (mainly) Danish, Dutch and German companies when I chose to leave the UK in late 1990 that keep me in my current life- style in Bulgaria and Romania. No need to make ironic comments – call it “reverse flow”……

The Scots and the Irish have a reputation for leaving their country to seek fame and fortune in far parts of the globe and have done fairly well out of it – although some of the early migrants were driven from their homes by rapacious landlords (The Highland Clearances) and famine.

Commentary

This short but masterly podcast about the situation puts to shame the outpourings of the corporate media which spew their poison at us every minute of the day. A real example of what a lone voice can achieve!!!! And the inestimable John Harris gives an important lesson in lexicology here

The initial responses of the German people and leaders are what we expected in the past when hearts and homes were open to those driven from their countries by forces outside their control. This was my parents’ response in the early 1940s when they took in a family belonging to the Free French forces stationed in my home town – I still remember the red, white and blue of the silver-crepe ornament which adorned our front window at Christmas in the 1950s; and our PE teacher was a refugee from the Greek Civil War……

But materialism and fear (the later instilled by the prejudice whipped up by the media) have hardened our hearts. It appears that the old spirit is still alive only in Germany….scenes at Munich central station described here. Two factors explain the initial positive German response – historical feelings of guilt and their current manpower needs - but that response is careless surely of the potential effects on the country’s social fabric. But the political position quickly changed

I must confess to having some difficulty myself with the initial welcoming response to the refugee flow from “liberals” whose secure lives all too easily lead them to an insensitivity about the anxieties of the average citizen.

Update from 2 November blog 

update from May 2017 https://www.theguardian.com/us-news/2017/jan/31/jared-kushner-grandmother-refugee-holocaust

Rural life in the early part of the century

One of my great fortunes in life is to have a mountain house which had stood empty for more than a decade when we first clapped eyes on it in summer 2000 and bought on a whim (and for a song). It needed a lot of work – it had no running water, electricity or insulation.

Indeed it was little more than a shell – its lower (stone) level hewn into the hillside having served as a shelter for family cows and the maturing of cheese; the wooden floor above as accommodation – kept warm in the winter by the heat of the animals below – and the attic as storage for the hay.   

It is part of a collection of houses which form one of the scattered villages which cling to the mountain valleys which stretch up from Brasov and Campulung and whose stories deserve to be told.

For the next few years, Daniela (living 200 kilometres south in Bucharest) would hitchhike almost every weekend; find the workmen and materials; lug the materials from nearby villages and manage the work of digging (water and sewage), building (bathroom, kitchen and stoves) and insulation. My excuse was that I was a few thousand kilometres further east and therefore managed to take in only a bit of the insulation; the construction of the subsequent central heating; back terrace; and loft conversion……   During that last bit of work we were delighted to find not only beer bottles from the 1930s but carefully-kept accounts of the sales of the cheeses – a real glimpse into village life….

The house may be legally (and emotionally) mine – but it is Daniela’s creation – down to the furniture, bookshelves, arrangement of the paintings and the Rene McIntosh stained glass-like designs…..

Only since summer 2008 have I been able to spend substantial time here (from May through to October) and get a sense of the sorts of lives people lived here in the twentieth century….centred around the church and its frequent saintdays whose piped incantations echo around the valley…..

I am a city boy but have grown to appreciate the superb air and silences here.

One small section of my library is devoted to books which try to give voice to this (dying) way of life – the titles include -
- Road to Alto - an account of peasants, capitalists and the soil in the mountains of southern Portugal; Robin Jenkins (1979)

- House by the Shore – twelve years in the Hebrides; Alison Johnson (1986)
- A Wild Herb Soup – the life of a French countrywoman; Emilie Carles (1991)
 - "A Year's Turning"; Michael Viney (1996) about life in a remote Irish location to which they moved in the late 1970s
-  Celestine – voices from a French village; Gillian Tindall (1996)
- "Mourjou - the life and food of an auvergne village"; Peter Graham (1998);
 - Harry Clifton's poetic "On the Spine of Italy - a year in the Abruzzi" (1999)
- War in Val D'Orcia: An Italian War Diary, 1943-1944; Iris Ortigo (2000)
-  Love and War in the Pyrenees; a story of courage, fear and hope 1939-1944 – Rosemary Bailey (2008)
 - Notes from Walnut Tree Farm; Roger Deakin (2008)
 - An Island in Time – the biography of a villagean Island in Time; Geert Mak (2010)

Recently I have been reading -
- The Stronghold – four seasons in the white mountains of Crete; Xan Fielding (1953)
- Thin Paths – journeys in and around an Italian mountain village; Julia Blackburn (2012)

All of such books make for gripping reading – but the last two I have found particularly powerful – perhaps because I am now spending more time with my 89-year old neighbor who was widowed earlier in the year. For many years in the 50s and 60s he delivered the post in the valleys here – on horseback! He must have some tales to tell!

Blackburn's book has touches of WG Sebald - poetic with small unfocused black and white photos...she befriended the old people in her village and gradually got them to talk about their lives....first time I had heard of the feudal system still prevailing there in the early part of the 20th century with the residents calling themselves "mezzadri" (half people) and being at the beck and call of "il padro"....    

Working Across Cultures - how it expands the mind

I opened a veritable Pandora’s Box of personal memories this week – with the post on memoirs……..

Then remembered a stack of large notebooks I had used in the 1980s to record both initial scribbles and final typed-up papers as I had struggled to make sense of the nature of the organisational venture I was then engaged in - trying to reshape a large bureaucratic system in the West of Scotland. And duly found about 1,500 pages – stashed away behind the Scottish section of my bookcase!!

As I dipped into them, I realized that I now write much better than then – indeed that I think more clearly……And how much of this I owe to my nomadic lifestyle of the past 25 years. 

In central Europe in the 1990s I needed to speak more slowly (generally through interpreters); had the time in the pauses, as the interpretation was being done, to think carefully about both what I should be saying - and how to say it. And, under questioning, I was having to explain more clearly what I thought my concepts actually meant!!

Far from being a nuisance, it helped me see things from other people's point of view. I was having to “relativise” – to be aware that the experiences and images certain words and concepts brought to my mind generally aroused very different images in my interlocuteurs’ minds – and to try to deal with this…..  

I was able to produce a detailed analysis of the 1980s venture only nine years later - thanks to the greater "distance" my nomadic work had helped me develop. A short Urban Studies fellowship in the mid 1990s in my old University (Glasgow) also helped. You can see the result in Organisational Development and Political Amnesia

All relevant to the flood of books which hit me this week – mainly collections of essays – a genre I have loved since my schooldays when Francis Bacon and Charles Lamb were favourites. The literary canon, apparently, distinguishes various forms of essay and “personal essay” is evidently the more precise term for the type I like. The Art of the Personal Essay is a 770-page collection with a superb introduction to the genre by Phillip Lopate who writes…….

The hallmark of the personal essay is its intimacy. The writer seems to be speaking directly into your ear, confiding everything from gossip to wisdom. Through sharing thoughts, memories, desires, complaints, and whimsies, the personal essayist sets up a relationship with the reader, a dialogue -- a friendship, if you will, based on identification, understanding, testiness, and companionship. (xxiii)

The personal essayist must above all be a reliable narrator; we must trust his or her core of sincerity. We must also feel secure that the essayist has done a fair amount of introspective homework already, is grounded in reality, and is trying to give us the maximum understanding and intelligence of which he or she is capable. . . . How the world comes at another person, the irritations, jubilation’s, aches and pains, humorous flashes -- these are the classic building materials of the personal essay. We learn the rhythm by which the essayist receives, digests, and spits out the world, and we learn the shape of his or her privacy. (xxiv-xxv)

The collection makes quite an interesting contrast with the other 700 page anthology which landed with a thud this week - The Lost Origins of the Essay by John D'Agata. Both volumes are international in scope (unlike John Gross’s 704 page classic The Oxford Book of Essays edited some decades ago which looks only at English writers) but D’Agata’s seems to have more focus on longer, Eastern works. Lopate’s gives us the range and writers we expect. Both are large and handsome but the Gray Wolf Press edition of The Lost Origins of the Essay is a real example of sensual work – with great quality paper, typeface and a delicate folding cover. And interesting background piece on that publisher here 

 

Three of Clive James’s explosive collections also await - Cultural Cohesion: The Essential Essays, 1968-2002; A Point of View; and The Revolt of the Pendulum: Essays 2005-2008. But

And I’m tempted to order George Orwell’s Collected Essays which I have been without for the past 4 decades….. talk about making up for lost time……

Intimations of Mortality

Those of us who enjoy good health don’t give a moment’s thought to the prospect of growing old and frail. Making a will should be a wake-up call but is all too quickly forgotten. I sometimes wonder if my inability to even start the process of applying for the pension which was rightfully mine some years back is not a sign of psychological resistance to the very notion that I am “getting on in years”!

The face that stares back at me from the mirror has still some resemblance to my old passport photos (the body doesn’t). When my mother made the decision at age 95 to transfer from the independent flat she had in a small and lightly ”supported accommodation” I vividly remember her looking around at her new neighbours – most of whom were considerably younger than her – and remarking (quietly) that there were a lot of old people around!

It is indeed all in the mind…..It’s almost 50 years ago that The Coming of Age by Simone de Beauvoir burst on the world 

In 1967, Beauvoir began a monumental study of the same genre and calibre as “The Second Sex”. La Vieillesse (The Coming of Age, 1970) met with instant critical success. “The Second Sex” had been received with considerable hostility from many groups who did not want to be confronted with an unpleasant critique of their sexist and oppressive attitudes towards women; “The Coming of Age” however, was generally welcomed although it too critiques society’s prejudices towards another oppressed group: the elderly. This masterful work takes the fear of age as a cultural phenomenon and seeks to give voice to a silenced and detested class of human beings.

What she concludes from her investigation into the experience, fear and stigma of old age is that even though the process of aging and the decline into death is an inescapable, existential phenomenon for those human beings who live long enough to experience it, there is no justification for our loathing older members of society – nor should the “aged” merely resign themselves to waiting for death or for younger members of society to treat them as the invisible class.

Rather, Beauvoir argues…. that old age must still be a time of creative and meaningful projects and relationships with others. This means that above all else, old age must not be a time of boredom, but a time of continuous political and social action. This requires a change of orientation among the aged themselves and within society as a whole which must transform its idea that a person is only valuable insofar as they are profitable. Instead, both individuals and society must recognize that a person’s value lies in his or her humanity - which is unaffected by age.

Thanks to campaigning efforts of bodies such as Age Concern (in the UK) and the efforts of prominent older people such as retired trade union leader Jack Jones and Joan Bakewell, I noticed signs about a decade or so ago of such positive developments….but the media and entertainment industry (which still tends to set the tone) is still remarkably “ageist. On Golden Pond was unusual for 1981 (with Henry Fonda and Katherine Hepburn as the elderly couple) but was a one-off - presumably the studios calculated they needed more upbeat messages.

More recently we have had the French film “All Together” with Jane Fonda and Geraldine Chaplin and, in early 2013,  another (more harrowing) French film. In the same year a Japanese politician was caught telling the elderly to hurry up and die but British think-tanks offered some reasoned discussions about housing options for the elderly in the UK and good material on the whole issue of images and perceptions of old age.

And the writer Penelope Lively had a more celebratory piece - 

So this is old age. If you are not yet in it, you may be shuddering. If you are, you will perhaps disagree, in which case I can only say: this is how it is for me. And if it sounds – to anyone – a pretty pallid sort of place, I can refute that. It is not. Certain desires and drives have gone. But what remains is response.

I am as alive to the world as I have ever been – alive to everything I see and hear and feel. I revel in the spring sunshine, and the cream and purple hellebore in the garden; I listen to a radio discussion about the ethics of selective abortion, and chip in at points; the sound of a beloved voice on the phone brings a surge of pleasure.
 I think there is a sea-change, in old age – a metamorphosis of the sensibilities. With those old consuming vigours now muted, something else comes into its own – an almost luxurious appreciation of the world that you are still in.

Spring was never so vibrant; autumn never so richly gold. People are of abiding interest – observed in the street, overheard on a bus. The small pleasures have bloomed into points of relish in the day – food, opening the newspaper (new minted, just for me), a shower, the comfort of bed. It is almost like some kind of end-game salute to the intensity of childhood experience, when the world was new.
It is an old accustomed world now, but invested with fresh significance; I've seen all this before, done all this, but am somehow able to find new and sharpened pleasure.

The following year, Jenni Diski had a much nastier take on old age in a piece called “However I smell”

Atul Gawande – author of the book I wrote about yesterday – may be a surgeon and Professor but is not your normal medic. In this interesting interview earlier this year in Guernica magazine he explains how he came to be able to give voice to his own uncertainties and to celebrate by example the importance of “listening” – something which medical training has apparently come round to only recently……  (this critical section of the interview is toward the end)  

The biggest thing I found was that when these clinicians were at their best, they were recognizing that people had priorities besides merely living longer. The most important and reliable way that we can understand what people’s priorities are, besides just living longer, is to simply ask. And we don’t ask. 

Guernica: How did your research on end-of-life care change how you behaved as a doctor? 

Atul Gawande: As a doctor, I felt really incompetent when trying to understand how to talk to patients and their loved ones about an illness that we were not going to be able to make better. We might be able to stave off certain components of it, or maybe we couldn’t even do that. And I felt unprepared when it came to having those difficult conversations and helping patients make those decisions.

I found that these end-of-life care experts were making me feel much more competent. They were giving me the words that I could use, and I began to use those words. I’d simply say to a patient, “I’m worried about how things are going.” I’d ask questions like, “Tell me what you understand about your health and your prognosis.” “Tell me what your goals are, if time is short.” “Tell me what your fears and worries are for the future.” “Tell me what the outcomes are that you would find unacceptable.”

This little newsletter also carries a useful overview on the subject

The photograph is, coincidentally, one of those from Australia's recent national photographic awards  

Facing up to our Mortality

About once a year a book has me on the edge of the seat and really challenged - Being Mortal – illness, medicine and what matters in the end seems to be this year’s book. It’s written by a rather special doctor of Indian origin who has been working in US hospitals and also writing for The New Yorker …. Atul Gawande

Initially it presents a rather harrowing description of what the onset of age does to our body – and how modern medicine responds….with more and more sophisticated (and expensive) treatment – increasingly in hospital. The deservedly acclaimed film  “One Flew Over the Cuckoo’s Nest” may be about patients in a “mental home” but the treatment which audiences saw exactly 40 years ago is all too evident in all institutions these days…..

In my parents’ generation people tended to die a few years after retirement but a mix of factors (eg the decline of manufacturing industry and medical advances) has added at least 10 years to “life expectation” in Europe and North America.

That led to political panics a decade or so ago about the fiscal burden of pensions (assuaged to an extent by the breaking of social promises and contracts) and the constant climb in health costs then led to campaigns to get us living more healthily. But the public continue to expect the best medical treatment and - when that fails - institutional care of “the elderly” who tend these days to be living on their own hundreds of miles/kilometres away from sons and daughters….       

Gawande paints an ugly picture of the suddenness with which people in their 70s can fall from autonomy to institutional dependence and regimentation and rightly accuses us all of failing to prepare for this.

I am as guilty as the next although a little voice has been encouraging me this past couple of years to “copy and save” articles and papers about ageing - on which I will draw for my next post

The heroes in Gawande’s story are some mavericks who couldn’t accept the regimentation; had a passionately-held vision of an alternative system which allowed people to assert the independence they had come to expect in their own homes; and had the guts, skills and perseverance to build examples of such alternatives whose results were not only cheaper but led to a better quality of life…..By 2010 the number of residents of such small complexes which spread across America was approaching the number in nursing homes. But then, Gawande tells us 

“a distressing thing happened – the concept of assisted living became so popular that developers began slapping the name on just about anything. The idea mutated from a radical alternative to nursing homes into a menagerie of watered-down versions with fewer services….concerns about safety increasingly limited what people could have in their apartments and defined ever more stringent conditions which would trigger discharge to a nursing home. The language of medicine, with its priorities of safety and survival was taking over again” (p101)

And the boards running such places wanted the profits which come from a larger scale than the original concept  

I was reminded me of the “sheltered accommodation” my mother chose to live in between the ages of 85 and 95 – cooking and shopping for herself. I checked and there it was – a complex of only seven flats – part of a charity which has more than 100 such places in the UK…So all is not lost!!!

But the importance of “autonomy” – whether in company structures or the way we live our lives……- is still hidden from most of us.......

The Art of the Memoir

Politicians have given narcissism a bad name - the story-line of too many of their autobiographies being "Look what I achieved - despite all the bastards out to get me". And yet there are superb exceptions such as Dennis Healey’s “Time of my Life” beautifully-written and wry study of politics when it mattered – with a dash of culture thrown in from time to time. En passant he mentions that Leonard Woolf’s 5-volume “Memoirs” were an inspiration - when I eventually got round to reading them I had to agree they were one of the best in the English language. By contrast Tony Benn’s 50 year series of “Diaries” are little more than a series of notes…..

Other examples of authors who led fascinating lives and whose account of them generally avoids the emptiness of modern political scribbles are -
• Arthur Koestler's 4 volumes - "an unrivalled study" as the blurb on the back of the third volume ("The Invisible Writing") puts it "of twentieth century man and his dilemmas"
- JK Galbraith’s “A Life in Our Times; Memoirs” offer an unsurpassable repast of memories and intellectual musings
• The various volumes of Simone de Beauvoir’s autobiography convey a powerful sense of an exciting new Europe taking shape in the post-war rubble.
• Writer Luise Rinser’s “Saturn auf der Sonne” (2nd part of her autobiography) does the same for Germany
• graphic artistTisa von Schulenberg’s harrowing little book “Ich Kann Nicht Anders” covers her life before the war….
• I also thoroughly enjoyed historian Fritz Stern’s “Five Germanies I have known”
• And, recently, novelist Gunther Grass’s so poetic “Peeling the Onion”
• Poet Dannie Abse’s “Goodbye Twentieth Century” is a gentle memoir
• Diane Athill’s various Memoirs are as good as they get
• Des Wilson, the great campaigner, I knew briefly in the late 70s and he was good enough to send me his rumbustious “Memoirs of a Minor Public Figure”
• Clive James’ output is almost unclassifiable – memoirs, essays, notes – give a real insight into a great mind, reader and writer…
- .Gregor von Rezzori is one of the most neglected of writers from lands which have been variously part of Austro-Hungary, CzechoSlovakia, Hungary, Romania and now Ukraine. Over thirty years he wrote marvellous prose about his early years in the town of Czernowitz when it lay in the northern redoubts of Romania. It is difficult to classify them – novels or memoirs? Memoirs of an Anti-Semite (1979) and Snows of Yesteryear (1989) generally appear as the former but to my mind can be read as “creative memoirs”.
• Amitai Etzioni and Richard Rose are two prolific academics whose foray into Memoir ( entitled respectively“My Brother’s Keeper” and (very jazzily?) Learning about Politics in Time and Space(!!) give a great sense of their intellectual development. And, like Fritz Stern, they straddle different countries…….

What exactly, I wonder, do we get from these attempts of creative people to make sense of their lives? What insights into human behavior? What lessons for us? There must be a Phd thesis in there somewhere??? (here are a couple of recent efforts to survey the field)

The painting is one of three I bought in May at an exhibition in the Military Circle gallery from a master of book graphics - Alex Ivanov