As a GP, I sighed with relief reading John Furse’s article on the NHS (LRB, 7 November). No lies on the side of a bus, just home truths. The critical letters the piece received in response do not reflect the changes that have already occurred on the frontline (Letters, 5 December).
Frank Dobson, as Tony Blair’s first health secretary, oversaw the introduction of the National Institute of Clinical Excellence (NICE), intended to help end the ‘postcode lottery’ in the availability of treatments. It has been a partial success but huge variations in availability of treatment remain. What has followed is an ever increasing barrage of guidelines, pathways and directions for clinicians, setting the parameters for what they can and cannot do. Young doctors and nurses, with no memory of any other way of doing things, treat these guidelines as if they were rules while general practice has been transformed into a Kwik-Fit operation that doesn’t give you the freedom to choose even the tyres your patient should have for their onward journey.
An elderly patient with a bad head injury attending casualty is seen by a triage nurse who is obliged to follow specific guidelines. He is treated for a facial cut and broken nose. But severe symptoms persist for four weeks. Only when he returns to see a doctor is a CT scan requested. The scan explains the symptoms. Had he been just a few months older at the time of the accident, he would have been old enough to qualify automatically for a CT scan.
Ankle and knee injuries used to be judged on their severity and other factors specific to the patient. Now the only pathway permitted is to direct the patient to make contact with his local ‘musculoskeletal service’, which is delivered by an outsourced private, profit-driven provider. After telephone consultations, he may, eventually, get to see a physiotherapist; only then might he be referred to an orthopaedic consultant. This may be more than six months after the initial contact. What cost the time off work, the limiting of mobility and exercise, the weight gain, the consequences for the patient’s mental health?
Another patient survives a heart attack because someone in the community performs CPR on her. After being taken to a major hospital, she is given a full cardiological and pulmonary work-up. Two weeks later a request arrives to refer the patient to cardiology for review. When the question is asked what blood tests or other cardiology tests were done when she was admitted the answer is none. New referral, further costs, more anxiety for the patient and her family.
The NHS is being dismantled, and the effects are felt daily by patients and staff alike. Everyone is struggling to practise safe care. So long as sensible thinking and commonsense selection of tests and referrals – specific to each individual – are excessively restricted by guidelines and by fears over costs, we will all suffer; and in the end, no money will have been saved.
Excellent essays by Thomas Meaney (LRB, 7 November) and Jérôme Tubiana and Clotilde Warin (LRB, 21 March) draw attention to the violence, oppression and crimes against humanity in Sudan. But why do both authors refer to events in Darfur as a ‘war’, while consistently avoiding the word ‘genocide’? Perhaps they are hesitant because political institutions have gone back and forth on the matter. As early as July 2004 the US Congress passed a resolution calling what was taking place in Darfur a genocide. But both the United Nations, in the initial report to the secretary-general in 2005, and the International Criminal Court in their initial investigation (also 2005), steered clear of a direct charge of genocide. The ICC reversed its decision in 2009 in issuing a warrant for Omar al-Bashir. Today, the actions of the Janjawiid militias in Darfur from 2003 onwards are no longer regarded as ambiguous cases by serious scholars of genocide, of Sudan, or of international legal opinion.
Whether or not events in Darfur meet the standard in international human rights law for genocide, you could be forgiven for thinking it meets the conventional understanding of the term: thousands of people were murdered as part of a centrally directed state strategy on the basis of their presumed ethnicity.
Avoiding the word is not a neutral stance. During the Rwandan genocide US State Department officials were instructed to avoid the word ‘genocide’ because using it implied the US government ought to act. And redescribing genocidal episodes as ‘wars’ has a long and dishonourable history. Turkish state denials of the reality of the Armenian genocide have frequently sought to frame events as ‘merely’ the sort of collateral damage that happens in war, and deniers of the Rwandan genocide are often keen to present the events of 1994 as an armed conflict between symmetrical sides, both of which committed regrettable war crimes. The original reasoning of the UN in resisting the label of genocide is chillingly reminiscent of the way the Turkish government has repeatedly represented the events of 1914: ‘Generally speaking the policy of attacking, killing and forcibly displacing members of some tribes does not evince a specific intent to annihilate, in whole or in part, a group distinguished on racial, ethnic, national or religious grounds. Rather, it would seem that those who planned and organised attacks on villages pursued the intent to drive the victims from their homes, primarily for purposes of counter-insurgency warfare.’
I will leave it to philosophers defending the doctrine of double-effect to assess the importance of the distinction between seeking to annihilate and pursuing policies in the knowledge that annihilation is a forseeable consequence. We know of Janjawiid attacks that involve going from house to house killing every man and boy and raping every woman and girl. We know there was aerial bombing of towns and villages. We know the bombings sometimes used chemical weapons. We know the Janjawiid pursued fleeing refugees, sometimes across international borders to what were supposed to be safe havens in Chad. To call this a war risks giving comfort to denialists and perpetrators, and transgresses on the dignity of victims and survivors.
Royal Holloway, University of London
May I complement Mike Jay’s excellent piece on Michael Neve with a few observations (LRB, 21 November)? Michael and I were contemporaries at Christ’s College, Cambridge. A vivid flashback: Michael silhouetted in the entrance to the college buttery, thin as a fishbone, unfashionably dressed in sports jacket and tie (this was 1968), his hair clipped. Quentin Skinner was entertaining a group of undergraduates at the table next to mine. He insouciantly called Michael over to join the group. Michael responded with almost military precision, drawing his feet together as if to click his heels and pushing back his hair with a hand before striding over. No hippy he.
When I joined the BBC a few years later I tried to get Michael on the radio as often as I could, though he was always slagging me off for not getting him ‘more gigs’. One of his most memorable broadcasts was a talk for a Radio Three Proms interval called ‘Was Hamlet mad?’, which brought together his considerable literary critical skills and his knowledge of the history of clinical attitudes to madness. We described the programmes we did together as examples of the long overdue highbrow backlash.
One high summer evening I invited him back to my office in the eaves of old Broadcasting House, where we drank white wine and smoked a joint. Looking back a little while later Michael asked me who else would have done that. I replied sheepishly that I didn’t know. ‘No one! No one!’ he roared, as if that rather ill-advised indulgence was the high-water mark of some obscure moral code.
After some years of travelling abroad I caught up with Michael again – now in his ‘Falstaff years’, as Jay calls them – and we became close friends. I can attest to those magisterial lunches. I came away from a particularly fine one with a reading list that included Charles Nicholl’s account of Rimbaud’s time in Africa – I was working on a song cycle about this subject at the time. I always felt that Michael, like Rimbaud perhaps, was living on the dangerous edge of things. His drinking and philandering were prodigious and he was capable of nurturing animosities of a monumental proportion. But he could also be immensely kind and warm.
Two years ago I remarried. Michael was already gravely ill and didn’t come to the wedding. My wife sent him some photos. The following was his extravagant response to her, a woman he had never met:
A million thanks, Mrs Perry! One wouldn’t have to be a learned anthropologist to acknowledge that weddings are almost always a wonderful thing, partly because they include everyone present and many others scattered far and wide. And these pix just go to prove that. I also need to record how thrilled I am for Mr Perry. I have known him now for over four decades and it is the coolest thing that someone as loyal and realistic and savvy and fun (that laugh!) has met you and is now married. It’s Purcell, it’s Keats’s autumn where there is a special kind of new beauty, when one knows where to look. He also reminds me of Christ’s and of Cambridge. In fact he is the only man from those college years whom I have known all the way through since then. I matriculated in 1968 and read history: I was the only public schoolboy reading for that subject that year, something that I constantly have to remind people when the whole Oxbridge thing gets brought up. I send complete congratulations and love.
This was the last communication we had from Michael.
David Runciman argues eloquently in favour of ‘a constitutional convention to establish a new set of ground rules’ (LRB, 5 December). The trouble is that real constitutional change is possible only in very specific circumstances. To take the relatively simple case of electoral reform, in European experience (to which the UK is no exception) significant changes in electoral systems have been possible only in the aftermath of war, civil war or a severe constitutional crisis (as happened in France in 1958, when de Gaulle was able to force through changes only because of the perceived threat of a military coup, or of civil war). Otherwise, such reform would require parliamentarians to behave like turkeys voting for Christmas.
In the UK, David Cameron’s coalition government did introduce a significant change through the Fixed-Term Parliaments Act of 2011, but Runciman (rightly) assumes it will be ditched as soon as possible by a newly elected Johnson government. Maybe the (extraconstitutional) use of the referendum in 2016 and its political fallout have created sufficiently dramatic conditions to permit a vote for electoral and constitutional reform. But I wouldn’t bet on it.
University of Eastern Piedmont, Vercelli
Rosemary Hill describes the Cyprus Emergency of 1955-59 as a ‘civil war’, presumably fought between the Greek and Turkish Cypriot inhabitants of the island (LRB, 7 November). The ‘emergency’ in question was declared on 26 November 1955 by Sir John Harding, the governor general of Cyprus, in response to a Greek Cypriot guerrilla campaign whose declared aim was to bring an end to British colonial rule and forge a political union with Greece. Attempting to defend their colony, the British flooded the island with troops, while Harold Macmillan, then foreign secretary, turned to the divide-and-rule chapter of the imperialist playbook and set about fomenting strife between Turks and Greeks. Any fighting between EOKA (Greeks) and TMT (Turks) was fabricated and ultimately incidental, and could hardly be said to constitute a conflict, let alone a civil war. The real war was the anti-colonial war that would culminate in the establishment of the Republic of Cyprus in 1960.
Katherine Rundell writes charmingly about Dante Gabriel Rossetti’s peculiar obsession with his beloved ‘ordinary wombat’, noting the animal’s surprising characteristics (LRB, 11 October 2018). But one of the tubby marsupial’s abilities – to scamper on all fours at a 25 mph clip for longer than a minute – has alas not saved it from a recent decrease in numbers. As Rundell noted, the common wombat could easily outpace Usain Bolt over a hundred metres, but it has less success outrunning Toyotas, Mercedes or Mack trucks on Australian roads. On a recent trip from Sydney to a small town two hundred miles west, I counted more than eighty ‘road kill’ victims, mainly kangaroos and wallabies, driven to search for water by the drought currently affecting much of the eastern Australian seaboard. But also among the carnage at the side of the highway were nine common wombats, bloated and with four stubby legs motionless and pointed skywards. Not much consideration of the wombat there.
Meehan Crist writes: ‘any report that fails to address climate change in a story about catastrophic fires, or floods, or storms (or migration, or elections or the global economy) is getting the story wrong’ (LRB, 21 November). In that case there is a hell of a lot of fake news about. It is in fact undeniable that the urgency and complexity of the ‘climate and the environmental crisis’ has not yet entered mainstream discourse. It is still overwhelmingly treated as an event, something specific and containable, just another disaster among the many the world faces every day. It is also unlikely that the current UK election is the last that will address it as just another manifesto promise. The LRB has to its credit reported on climate change from time to time in its first forty years but it has failed by some margin to meet Crist’s modest criteria. Unless things change radically, by the time of the next 40th anniversary it will be too late.
Meehan Crist correctly notes the link between the recurring California wildfires and climate change. However, we should not overlook the role of government policy in encouraging development in high-risk locations. We subsidise hazard insurance so that insurance rates bear little, if any, relationship to the level of risk. When homes are threatened by wildland fires, we repeatedly send firefighters into harm’s way to save what shouldn’t have been built in the first place. When coastal communities flood, we rebuild in the same locations knowing full well that the same thing will happen again. While the opportunity to arrest climate change may be passing, we can still control what gets built in the areas most affected by it.
Troy, New York
Jonathan Rée refers to G.E. Moore as Bertrand Russell’s friend (LRB, 21 November). But I remember a passage in Russell’s autobiography in which the two of them were having a philosophical discussion when Russell suddenly interjected: ‘You don’t like me, do you, Moore?’ ‘No I don’t,’ Moore replied, and the discussion immediately resumed.
Greensboro, North Carolina
The works Jamie Callison proposes as expanding ‘the canon’ of David Jones’s writing are among those Jones deliberately chose not to publish (Letters, 21 November). To consider them simply as additions to the canon is like valuing Jones’s rejected visual try-outs and preliminary sketches as equal in value to his finished, signed and exhibited paintings and inscriptions: something Jones said he hoped would never happen. Omitted from Callison’s consideration are two poems that actually ought to be included, which Jones prepared for publication but was prevented from publishing by the paper shortage at the start of the Second World War. They are collected in the volume Wedding Poems, posthumously published in 2002.
John Lahr misattributes the line about Manhattan being ‘an isle of joy’ to the Gershwins (LRB, 21 November). It comes from Larry Hart’s lyric from 1925: ‘The great big city’s a wondrous toy/Just made for a girl and boy/We’ll turn Manhattan into an isle of joy.’
Kindly ignore the request from the New Zealand ambassador to Madrid for a third staple (Letters, 21 November). This would make it impossible to fold the LRB, which really is the only way to read it. Mind you, four staples would work.
I can’t share Nigel Fyfe’s hopes for an extra staple; it’s hard enough to tear off a page for the compost bin.