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And now, breaking news from our 2030 correspondent: Trump is here to stay

I’ve just spent a few minutes digesting the transcript of an interview in with a CNN analyst, in which the sage tells us that things are looking up for Donald Trump in the one area that seems to matter more to the president than any other: his popularity.

I won’t go into the details of why. The whole thing is rather nerdy, especially to someone like me whose prime motive for taking an interest in the United States these days is down to the fact that the oligarchs running the country are capable of ending my life as well as that of everyone else on the planet. And more likely to than ever before.

It seems that the hopes of the anti-Trump forces are focused on this year’s mid-term elections. If the Democrats can take the Senate or the House of Representatives, they have a good chance of stymying his legislative programme (to the extent that such exists), just as the Republicans frustrated Obama.

If they can take both, then the prospect that they can impeach the rogue moves from unlikely to possible – though still not very likely, unless we learn more about Trump’s misdeeds in the interim.

Now I’m a simple person, and it seems blindingly obvious to me that the Democrats can caterwaul all they like about healthcare, immigration, inequality and the fact that the leader of the free world likes to grab pussies and romp with porn stars, but none of this righteous outrage will make a blind bit of difference to Trump’s prospects unless the Democrats can come up with an anti-Trump.

Someone with charisma, impeccable personal values, free from the taint of corruption, preferably youngish as a contrast to Trump’s senile malevolence. Someone with his own hair, because we know how much these things matter to Americans. Unfortunately such a person will probably have to be a he, because the Democrats aren’t likely to take a chance with a woman until the misogynistic old pussy-grabbers die off, which will take at least a couple of general election cycles.

The candidate will need to be sufficiently mainstream not to frighten the financial horses. He’ll probably be mealy-mouthed about guns, Israel and the religious right. Above all, he’ll need to inspire faith, enthusiasm and optimism. And here’s the important bit: he can’t be boring.

Almost certainly, if he exists, he’s unlikely to emerge before the mid-term elections, which means that the Republicans are highly likely to retain a modicum of control of Congress.

All of this is important, because in 2020, the election will not be about the economy. It will be about personality, and the credibility of that personality. In normal times you would expect the incumbent President to win, unless, like Jimmy Carter, he’s seen as a bit of a disaster.

But Trump is different. Even if he manages to wriggle out of his Russia difficulties, the chances of his putting his foot back in his mouth and choking himself over the next two years and ten months have to be pretty high.

Should he do so, then the opponent who is least like him surely has a great chance to win.

The election will be about personality because Trump has successfully elevated personality over politics, and image over ability. Which explains why the Democrats, desperately clutching at straws, touted Oprah Winfrey as potential candidate after her speech at the Golden Globes. An inspiring person, yes, but could you imagine her with a finger poised on the nuclear button, or giving Putin a piece of her mind? (Actually, the answer to the Putin question is likely to be yes, because she’s unlikely to be in his thrall.)

The same probably goes for other celebs tipped for political careers: Tom Hanks, George Clooney and so forth.

So the Democrats, and all of us non-Americans who hope for a speedy termination of Trump’s presidency, are left with who? The old warhorses – Biden or Sanders? Perhaps. After all it would be unlikely that a 74-year-old Trump would be able to accuse them of being past it. Or maybe they’ll be tempted to skip a generation and go for a young wannabe like Joe Kennedy, who delivered the response for the Democrats to the president’s State of the Union speech.

It’s possible that the 2020 primaries will throw up some hidden gem of a candidate, as they did in 2008 with Obama. But if so, that person is leaving it rather late to raise their profile. So it seems that the Democrats’ only chance will come if Trump self-destructs.

But perhaps all this is academic.

I read a news story this morning, admittedly from an esoteric source, about a guy who claims to be a time-traveller from 2030. He states definitively that Trump will be re-elected in 2020. He makes other predictions that suggest that the world will not be in cinders in twelve years’ time, which is a bit of a relief. He also says that time travel exists today, but that it’s only used by “top secret organisations” – reptiles controlling the CIA, I would imagine. Apparently, his claims have been verified as “not lies” by a polygraph machine. So what is not untrue in the perception of the person being tested must be true, right? Very Trumpian.

The mind boggles. Perhaps the Democrats could borrow Abe Lincoln for a few years before sending him back for his rendezvous with the assassin’s bullet. Except that Abe was a Republican, so he wouldn’t get a look in against The Donald.

If the top secret organisations are indeed using time travel, I’m surprised they haven’t lifted The Saviour out of Nazareth on an assignment to bring forth the End of Days. That would certainly appeal to Mike Pence. However, I suspect that JC would be so horrified by his gun-toting, immigrant-hating, camels-passing-through-the-eye-of-a needle American disciples that he’d make a quick getaway back to Gethsemane.

Should time travel already have been invented, you can certainly bet on Trump controlling it rather than the Democrats. So if there appears to be no successor nasty or amoral enough to take on his legacy in 2024, he could always bring PT Barnum over for a sabbatical from his circus business.

On the other hand, by that time The Donald may have succeeded in suspending the constitution and installing himself as President for Life, assuming the viagra doesn’t get him first.

Even if we can’t do anything about it, we really need to have the opportunity to prepare for such an unpleasant possibility. So I would suggest that our time traveller needs to undergo a slightly more rigorous interrogation than he has experienced thus far. If he keeps going on about paradoxes preventing him from revealing all, a spot of waterboarding would surely do the trick.

This is madness, of course. But hardly less mad than the current state of politics in America. Whatever happens between now and 2020, the dominant theme will be “It’s the personality, stupid”.

The more outlandish the better, no doubt. Lord help us all.

Winter Reading: Two books to keep outrage fatigue at bay

There have been times over the past few months when I’ve felt myself succumbing to a malaise. What’s the point in adding my voice to the chorus of disapproval – in my echo chamber at least – at the antics of Donald Trump, whose malevolent acts and attitude spreads way beyond the shores of the United States?

What’s the point in ranting about the incompetence of the British government in its handling of Brexit, and the vicious attacks by the likes of the Daily Mail on anyone who sees things differently from its bombastic editor?

Why continue to be angry about the role of allegedly responsible countries in prolonging the suffering in Syria? And why rage about the relentless encroachment of Israeli settlers, and the detention of a 16-year old girl for slapping a soldier after the death of her relatives?

And if we can’t be bothered to raise our voices about these issues, how will the people of Yemen and the Rohingya in Burma get an ounce of our sympathy?

The other day, someone came up with a phrase to describe the malaise: outrage fatigue.

It would be quite possible to spend all day absorbing stories on any of these subjects. And then what? Do you shout and scream, and bore your friends (who are starting to think you’re boring enough already)? Do you march until your feet are sore? And if, like me, you blog, do you post endless polemics in basically the same themes?

Or do you retreat into yourself, thinking “what the hell, there’s nothing I can do anyway. Nobody but a few journalists, lobbyists and twitterati really give a shit about this stuff. How foolish to think that Trump can be brought down, Brexit stopped and all the affronts against human decency elsewhere magically resolved”?

I’m not at that point, but there are times when I fear that that’s where I’m heading.

Then I come across On Tyranny: Twenty Lessons from the Twentieth Century by Timothy Snyder. He’s a professor of history at Yale University. The book is about what we can learn from the rise of fascism and communism, and what we can do to prevent the transformation of democracies into tyranny in our century.

It’s mercifully short. His first, perhaps unintended, lesson, is that you don’t need to write a 500 page tome to get a powerful message across. My volume is a mere 126 pages. Oh joy.

Each of his twenty lessons begins with a succinct piece of advice. Number 18 for example:

Be calm when the unthinkable arrives

Modern tyranny is terror management. When the terror attack comes, remember that authoritarians exploit such events in order to consolidate power. The sudden disaster that requires the end of checks and balances, the dissolution of opposition parties, the suspension of freedom of expression the right to a fair trial, and so on, is the oldest trick in the Hitlerian book. Do not fall for it.

He then goes on to talk about the Reichstag Fire, after which Hitler seized the opportunity to impose a one-party state and round up those who opposed Nazism. And Putin, who used the attacks on a Moscow theatre and the school in Beslan to seize control of private television and do away with elected regional governors.

Though Snyder didn’t cite recent events in Turkey, President Erdogan’s rounding up of journalists after the attempted coup also comes to mind.

Throughout this slim volume, Snyder quotes extensively from writers with direct experience of the twin tyrannies of fascism and communism, such as Hannah Arendt, Vaclav Havel and Eugene Ionesco. His arguments are eloquent and compelling.

Although you sense that his lessons are principally aimed at Americans, whose democratic institutions he sees as being under threat by Trump and his henchmen, they are just a relevant to democracy still worth of the name, including my own. Perhaps for that reason he doesn’t mention Trump by name anywhere in the book – simply referring to him as the president. He writes for all of us who have not yet fallen under the yoke of authoritarianism.

On Tyranny serves as something of a morale booster. Snyder reminds me that if people like me, and millions like me, simply lie down and accept that might is right, and that we should always accept the will of the people, no matter how fraudulently that opinion was manipulated, then we shouldn’t be surprised if the tyrannies of the last century are repeated during this one. Buy it, read it, and then read it again.

Another book reminds me that no matter how old and decrepit we are, we are still capable of small acts of resistance against those who would wish to control our lives. Hendrick Groen, if he actually exists, is an 85-year-old resident of an old people’s home in Amsterdam. He, or whoever uses the pseudonym, has written a sequel to The Secret Diary of Hendrick Groen, 83 ¼ years old. It’s called On the Bright Side.

In the new book, which the publisher describes as a novel, Groen describes the adventures of his Old But Not Dead Club, as they sally forth despite their various ailments to destinations chosen by each of the eight members in turn – restaurants, museums and cultural events. Back at the home they carry out a quiet campaign of subversion against the authoritarian instincts of Mrs Stelwagen, the manager.

Like the first book, it’s touching, funny and full of gentle yet biting social commentary. It’s also a poignant reminder of how the older we get, the more our world shrinks and our power as individuals slips away.

What both books tell me is that while we have the power, we should be sure to use it. So I’m afraid that I shall have to continue to bore my diminishing circle of friends for a while yet.

Outrage fatigue will have to wait.

A doctor’s mistake, and the potential consequences for healthcare in Britain

The recent case of Hadiza Bawa-Garba, a British hospital doctor convicted of manslaughter and subsequently barred for life from practising after causing the death of a child through her errors and omissions brings to mind one fundamental factor: Jack Adcock’s death was, at least in part, the result of failures in communications.

Matthew Syed in The Times painstakingly relates the circumstances of the death of the 6-year-old back in 2011. Before discussing the case itself, he talks about the aftermath of three aircraft accidents that happened in the United States because pilots were so busy attending to a critical problem that they ignored other factors that led to the planes crashing:

When cognitive load is high, decision-making can be compromised. “Situational awareness” is the term used to describe the capacity of a crew to keep track of the multiple factors that together impinge on safety, the various pieces of the jigsaw that collectively provide perspective. When multiple demands are placed on a team, situational awareness can be undermined; pieces of the jigsaw (even seemingly obvious ones like the alarm) are missed.

This is why the aviation industry did not respond to these crashes and near-misses by blaming the professionals involved, but by learning key lessons. It led to a reformed approach to teamwork, the introduction of new checklists and a range of other changes, including strategic checks and balances. These accidents were tragic, but they also acted as a pivot to make air travel safer.

He goes on to describe the circumstances of Jack’s death, and in particular the demands on Dr Baba-Garwa’s attention:

– The consultant and another senior doctor responsible for the paediatric ward were absent

– She was required to work for 13 hours without a break

– She was responsible for six wards over four floors

– She carried out a series of life-saving interventions over the period, continually moving from patient to patient

– The IT system was down for four hours, so one of the doctors she supervised had to phone for blood results, making her unavailable

Nonetheless, a jury in 2015 found that her mistakes were sufficiently bad that they found her guilty of manslaughter. She was given a two-year suspended jail sentence. Earlier this week the Appeal Court upheld the General Medical Council’s application to have her name erased from the medical register, after an earlier tribunal ruled that she should be allowed to return to practice after a one-year re-training period.

It’s a complicated case, and if you’re sufficiently interested, you might want to read the Appeal Court judgement. Also read Matthew Syed’s article, which is both a mitigation and a warning about the dangers of a blame culture in the National Health Service.

I share his concerns. Medical negligence cases in the UK and in the United States are normally dealt with through civil lawsuits. Criminal prosecutions are very rare, and usually deal with deliberate acts – such as those of the mass murderer Dr Harold Shipman – as opposed to errors and omissions. Dr Bawa-Garwa was by testimony of her peers and supervisors an extremely competent doctor. Her career was ruined by one set of failures made in a short-staffed hospital amid a firestorm of competing claims to her attention. She continued to practice to a high standard without incident during the four subsequent years it took for a tribunal to suspend her.

I wonder whether public interest was served by this valuable resource being cast into the outer darkness.

Two other questions occur to me. First, if Jack hadn’t died, but the errors committed had been identical, would Dr Bawa-Garwa have been suspended? Second, if the doctor had been a male registrar with outstanding communication skills (think of Dr Ross, George Clooney’s character in ER), who apologised to the bereaved parents, would the same sanctions have been applied to him? In other words, did the fact that the offending doctor was female, black and a Muslim make it more likely that the parents would seek “justice” for their son?

I know that I’m entering dangerous territory here. I’m not accusing the parents of racism or Islamophobia. How could I? I don’t know them. I’m merely questioning whether an unconscious bias might have been at play in this case. How many of us, in our hearts, would not agree that we would be less nervous, for example (and this was not an issue in the case of Dr Bawa-Garba), if we were being treated by a doctor whose command of English was not as good as ours? No matter that the doctor concerned might be the best in the world, we might still be nervous. It’s the “not like me” factor at play.

Which leads me to a story about communications.

A few years ago, I was doing a workshop on the subject for a group of doctors, nurses and administrators in a highly-regarded Saudi hospital. One of the delegates, a consultant surgeon, spoke about an operation that went bad. A young girl was paralysed as a result.

After the operation, the surgeon asked his team to meet the parents and discuss the outcome, and the reasons for the failure of the operation, one of which was a critical error by the team.

In the meeting he explained the circumstances to the devastated parents without hiding any aspect of the operation. He told them how distraught they were at the outcome. He then asked the parents to speak about their daughter. The father stood up and spoke for half an hour. He was understandably emotional. He spoke about his daughter, her schooling, her hobbies and her aspirations in life, now severely circumscribed. The surgeon and his team didn’t interrupt them. They just listened.

When the father finally sat down, the surgeon offered his sincere apologies and sympathy for the child. He asked the father whether there was anything else they could do for the family. No, replied the father. He said that he was grateful to be listened to, that the fate of his daughter was the will of God, and that he would not be taking any action against the hospital.

Leaving aside the fatalism that is more common in Muslim countries – acceptance of the will of God – would the family’s attitude have been different if the meeting had not taken place? Almost certainly. The bereaved wanted more than anything else to be listened to. The surgeon, by his action, met that need. Not only did he listen, but he humanised his team in the perception of the parents. These were human beings, fallible like all of us, who made a mistake in an attempt to improve the daughter’s life.

I couldn’t teach that guy anything about communications. In fact I suggested that he should run the workshop instead of me.

Perhaps if Dr Bawa-Garwa had been part of that team, she would have been able to diffuse the understandable anger of Jack’s parents, and, in the process, overcome any unconscious bias on their part. But she would most likely argue that she didn’t have the time. Not even the time to express condolences to the family. Was that the mistake that had the greatest impact on her subsequent career?

Which brings me to another thought, again on communications. I’ve just finished an impressive and deeply moving book by a palliative care consultant, Katherine Mannix. In With the End in Mind, Dying, Death and Wisdom in an Age of Denial, she presents a collection of cases from her experience.

Her clear message is that in an age when we’re programmed to ignore or even deny the inevitability of death, effective communications can overcome the fear of death, not only on the part of the dying themselves, but also among their loved ones. Dr Mannix is not only an expert in palliative care – treating the symptoms, particularly pain, that can cause an agonising end. She is also a practitioner of Cognitive Behaviour Therapy (CBT). She uses her skills to help overcome the destructive loops of reasoning that make it more difficult for patients and loved one to accept the inevitable. The elimination of blame and recrimination, for example. The focus on living to the end rather than dying. Attention to the needs of the patient beyond desperate medical intervention that might prolong life, but that bring no quality in the living.

What’s abundantly clear from the book is that she and her colleagues work wonders, not only because of her clinical expertise, but through her superb communication skills.

Again, would she have been able to practice those skills so effectively if she had been in Dr Bawa-Garwa’s shoes on that fateful day? Perhaps not, but isn’t that an indictment of a system that allows a doctor just back from maternity leave to take on the responsibilities normally assigned to a consultant and a fully staffed team of doctors, and to have to work with a team of nurses – mainly from agencies – who have no experience of the paediatric ward in which they were placed as temporary staff? Not only that, but of a system that fails to equip all its clinical staff with the necessary skills to communicate effectively with patients, staff and loved ones?

To return to Matthew Syed’s article, there have been hundreds of comments by doctors arguing that standards of care cannot easily be improved if clinical staff are afraid that each mistake they make – and there are many in a huge organisation such as the NHS – will result in the end of their careers. Here’s one such comment:

Sir, Throughout my career as a consultant in intensive care I was regularly forced to make compromises in the care my team delivered (letters, Feb 9). There is no doubt that patients died as a result. If there are no beds available in intensive care, or too few doctors and nurses, then patients are refused admission, discharged too early or transferred elsewhere while potentially life-saving elective procedures are cancelled. Was I to blame for avoidable deaths or should I have downed tools in protest at being asked to do a job without being given the resources to make it possible?

You could argue that he was lucky, and Dr Bawa-Garwa wasn’t.

It seems blindingly obvious that in such situations, the emphasis should be on learning first, and consequences for those who make the errors second. Only in extreme cases should sanctions end careers. I’m not medically qualified, so I don’t know how Dr Bawa-Garwa’s actions rate on any kind of scale of negligence. Nor, I suspect, did the lay jurors who convicted her of manslaughter.

Any system that inhibits the honest and open investigation of errors and omissions with a view to improving clinical practice must be looked at with an extremely sceptical eye. The potentially devastating consequences of the case to the NHS – in terms of doctors covering their backsides by ordering tests to confirm their clinical judgements, difficulties in recruiting doctors in this branch of medicine because of the personal risk involved, and a time-consuming increase in paperwork – are spelt out in another Times article by Jenni Russell.

Finally, one more thought. The doctor’s career is over, unless further legal appeals succeed. Are there parallels?

Let’s say I’m driving down a motorway on a rainy night, trying to get home to my family, and I lose patience with a line of slow moving cars on the middle lane, and a couple of cars blocking the outside lane. I decide to overtake on the inside, and I crash into a truck that I didn’t see because of the poor visibility. I cause a pile-up, and people are killed and injured. I’m prosecuted, and convicted for dangerous driving. I go to jail for a couple of years, but eventually I get my licence back.

Is it fair that Dr Bawa-Garwa should never be allowed to resume her career after one fatal error, whereas I would be able to get my driver’s licence back? We both may have made one mistake that we will regret for the rest of our lives, but the doctor is unable to make amends by saving lives in the future.

Just a thought.

Many thanks to my wife, whose medical knowledge and interest in the case have been a great help to me in writing this piece.

RetroSaudi: Staying Alive

Sulaiman Habib Hospital, Riyadh

Wait outside any well-appointed private hospital in London, and you will find among the patients entering and leaving large numbers of men in western clothes who would look just as natural in the traditional thobe worn by Saudis and the citizens of other Gulf countries.

With them are women, covered from head to toe in black robes. Some have their faces covered, some don’t. Britain’s hospitals do a roaring trade treating the ailments of their wealthy Arab patients.

You might think that a lack of decent hospitals in their home countries leads them to seek help in London. This is not necessarily so. Although some go abroad for treatment of serious conditions because they believe that they can find the best-in-class care for that illness. For others a minor ailment or the perceived need for cosmetic surgery is an opportunity for a holiday outside the country, not just for the patient, but for family members. In other words, health tourism.

But back in Saudi Arabia, the majority of people can’t afford such travel. They are reliant on the services they find in the Kingdom, either from government hospitals or from the many private hospitals and clinics.

This latest piece in my RetroSaudi series is about healthcare in the Kingdom – as it was thirty years ago when I first wrote about it, and as it is today. My intention is not to provide a learned analysis of a big subject. As in 1987, I can offer observations and impressions, as well as a few oddities that made me laugh back then.

Since I started returning to Saudi Arabia in 2008, I’ve gained a deeper insight into the country’s health system through work I’ve done in a number of hospitals. Even in the 80s I was not entirely removed from the system, because my wife ran emergency rooms and outpatient clinics throughout our time there together.

Before I launch into my observations from 1987, I should say that Saudi Arabia is blessed with talented and dedicated doctors, nurses and health administrators, many of whom were trained abroad, and an increasing number through domestic universities . It’s always been a pleasure to meet and interact with them.

Healthcare may have been patchy in the past, and still is in some areas, but not for the lack of people who want to do their best for their patients.

Then (1987)

Saudi Arabia is a country whose citizens pay more deference to the medical profession than to any other group except the religious sheikhs and the royal family. Health, or rather illness, is such a preoccupation that the newspapers devote thousands of column inches to the subject every week.

Taking self-harm to extremes

Aleph ouch!

Typically, Tuesday’s copy of the Arab News devotes several features to medical breakthroughs. In a country where officially homosexuality and drug abuse are non-existent, the plight of the hapless blood recipient receives most attention, since this is the only explanation given for the spread of AIDS in the country.

Few countries – apart, perhaps from my own – pays so much attention to diet, with so little effect. The daily syndicated advice columns, “Harvey Frankenburger’s Diet Tips” and so on, are devoured by the pear-shaped masses, and then presumably ignored.

There is also a plethora of human (or inhuman) interest stories along the lies of: “Woman, 90, gives birth to monkey after 10-year pregnancy”. The weirdest stories seem to originate from the Middle East or the Indian subcontinent, which is hardly a surprise since many people in both regions are firm believers in magic. What is surprising is that so many papers report the stories as fact.

I never found out what the mermaid post-mortem revealed

Why this obsession with medicine? Some would say that the lack of external stimulation in a person’s life drives their attention towards the ailments, real or imagined, that blight their existence. The opposite of getting on with it, I suppose.

Certainly, in my experience, the appearance of a pimple or a bad bout of indigestion is often cause not only for a visit to the emergency room but for at least three days of sick leave. But then many Saudis have never really felt that they need sick leave. It’s enough to say “I’m tired”, for everybody to understand that the person suffers from an ailment that is as likely to originate in the mind as in the body, and is therefore definitely worth a couple of days off.

Despite their occasional bouts of hypochondria, Saudi men have a macho image of themselves. The older generation, who remember the days before hospitals and hand-outs, see themselves a strong as lions, contemptuous of physical comfort. The idols of the youth, on the other hand, are pop stars and footballers, not hunters and desert-dwellers. Sadly, the physical condition of city-dwellers leaves much to be desired. A reluctance to do physical work, brought about by the availability of foreigners to do the rough stuff for them, has taken its toll on the average citizen of Jeddah or Riyadh. Out of their glamorous sports cars step pitifully skinny guys you could knock down with a feather, or else alarmingly large ones you could never imagine being able to climb in, let alone out, of a Ferrari or a Porsche.

So what do the Saudis do to preserve the health of their pampered citizens? Quite a lot, actually.

Ten years ago the main public hospital in Jeddah was Bab Sherif, housed in a tenement-like building dating from the mid-50s. It was an institution in which, if you survived the surgeon’s knife you still had to contend with the eccentricities of the nursing staff, with raiding parties of cockroaches in the bedding, not to mention motheaten feral cats stealing your lunch.

That assumes, of course, that you managed to get there in the first place. First you had to make your way across potholes deep enough to stop a tank after D-Day, driven in an ambulance by an out-of-work racing driver who managed to avoid each obstruction, human or otherwise, by a hair’s breadth. By the time you got to the hospital there was a decent chance that you would be dead on arrival through fear. This perhaps explains why the patients of Bab Sherif viewed their lot so positively. They had already survived the worst.

The only occasion I visited the hospital was for the obligatory donation of blood in exchange for my driver’s licence. This involved sticking my arm into a hole in the wall. On the other side an unseen medical technician was waiting to insert the needle. I can only assume that the needle was clean, since I didn’t subsequently develop AIDS or hepatitis. But I did worry for a while.

Today they’ve replaced Bab Sherif with a multitude of gleaming public hospitals and private clinics. Business is booming. Every day the newspapers shout out the latest achievements of Saudi healthcare: test-tube babies, kidney transplants and all. The Saudis are so proud of their healthcare system that descriptions of complex medical seminars appear on the front pages.

Imagine the Daily Mail or the Washington Post running a headline on its front page such as “Causes of dimuscular ventricalities of the pericardial sac discussed”. The prestigious private hospitals, of which there are many, import world-renowned doctors for well-publicised visits, and treat them like rock stars. You half expect them to be accompanied by minders with tee shirts over their beer guts bearing messages like “Magdi Yacoub and the Fibrillators, Middle East Tour 1987 – the Show That’s All Heart”.

Dr Bakhsh was a hospital beloved of expatriates

The private hospitals are hideously expensive. They give you a blood test and X-ray for any complaint. But at least they give you a modicum of choice about your treatment. They’re also not shy about announcing their acquisition of sexy new equipment.

One area of medicine that the Saudis haven’t come to terms with is primary healthcare. There are no neighbourhood clinics, health visitors or doctors who will come and visit you. Only hospitals. Often enough, unless you’re a road accident victim, you come to them, not them to you.

Now (2018)

Two things strike me when I revisit what I wrote in 1987. First, that I was writing with a somewhat supercilious expatriate consumer’s perspective. And second, there was almost nothing about women’s health. It’s all about the men.

Having spent several recent years running management and personal development workshops in the Saudi health sector, I know quite a lot more now. In those days I rarely met a Saudi woman, let alone had a lengthy conversation with one. But working with hospital staff – both male and female – has been a revelation. The women I’ve met are smart, enthusiastic and highly motivated, often more than the men.

Thirty years on, you would have expected the gaps to have been filled, and that with the huge sums the government has invested in healthcare, there would be a uniformly high standard of care, whether private or public.

Sadly that doesn’t seem to be the case. While there are a number of first-rate private hospitals, there are also some pretty awful ones. Medical negligence cases abound, and in one or two cases the government has had to step in and close the worst offenders.

In the government sector, again, the care is not uniform. The best hospitals are those operated by the military. They provide a high standard of care, and they train large numbers of Saudi doctors and nurses. Government hospitals in towns and villages are not, I’m told, of the same standard.

Healthcare for expatriates depends on what they can afford. Ten years ago the government decreed that every foreign worker should have private health insurance. But as with schemes elsewhere, there are different levels of coverage, and therefore of care.

That obligation has now been extended to Saudi citizens in the private sector. And for good reason, since the cost of treating lifestyle diseases – obesity, diabetes and heart disease – is, as we well know in the United Kingdom, cripplingly expensive.

Saudis have other health issues to contend with. For cultural reasons, consanguineous marriages – unions between close relatives – are still common. Although the government promotes screening for genetic conditions that might make close marriages inadvisable, they still take place on a regular basis, to preserve wealth, as well as family and tribal bloodlines.

As for women, two factors contribute heavily to health problems. First, Vitamin D deficiency resulting from the lack of sunlight among those who are required to cover up when venturing outside and don’t have the opportunity to catch the sun at home. And second, sports for women have been actively discouraged until recently. While women from wealthy families have always pushed back against this, and found their own ways to exercise in private, and those in rural areas still work in the fields, there are still many women in towns and cities whose only exercise is wandering around shopping malls.

Depression is another problem. Women who are aware either through experience of travelling or studying abroad, or through a regular diet of satellite TV, often feel trapped in their home lives, unable to live even moderately independent lives compared with their sisters in the West, or even their female neighbours in the Gulf. This is changing, as the government introduces a degree of social liberalisation, and encourages women into jobs. But often they are constrained not by wider society, but by their own families, whose conservative values do not allow them to contemplate their wives, daughters and sisters living lives beyond their control. This post from a female blogger living abroad powerfully describes the symptoms.

Saudi Arabia has other challenges that other countries do not have to face. The biggest is the potential for epidemics brought about by the massive influx of pilgrims during the Haj. It’s a melting pot for bugs imported from thirty countries. That there has been no outbreak of a serious infectious disease in living memory is a tribute to those who manage the whole process – doctors, civil servants and volunteers.

In recent years the Saudis have had to contend with MERS, a nasty and often lethal coronavirus that keeps popping up in clusters around the country. Again, however, they have managed to prevent a general outbreak.

Leaving aside the epidemics and the chronic ailments of the Saudi population, would I, if struck down on a visit to Riyadh by some critical condition, be confident that I would receive the best care in one of the Kingdom’s high-status institutions? The answer is yes, provided I was lucky enough to find my way to a National Guard hospital, or to the King Faisal Specialist Hospital in Riyadh. If you don’t believe me, ask Frank Gardner, the BBC journalist who in 2003 was shot down by Al-Qaeda operatives in Riyadh, and whose life was saved by the Faisal Hospital.

If I found myself in a car accident halfway between Jeddah and Riyadh, perhaps I wouldn’t be so lucky. But not for the lack of trying on the part of the helicopter rescue crews I met in Jeddah on a regular basis, should I have the fortune to be within their range.

The Saudi healthcare system is definitely getting there, but it’s a big country, and sadly there are times when you need to be at the right place at the right time. But I guess that’s the same just about anywhere. It’s only a question of degree.

Other pieces on Saudi healthcare:

RetroSaudi: The Joys and Perils of the Deskbound

Debate on Bureaucracy, Arab News, Jeddah c1987

It’s time to return to the RetroSaudi archives. This time the spotlight shines on Saudi Arabia’s bureaucrats. But first, a modicum of context.

Government bureaucracies appear to be under attack both in the US and Britain, though for different reasons. In the US, government workers are disgruntled at hiring freezes and at the scrapping of regulations that they perceive to be beneficial to the country, if not to the interests of Donald Trump’s corporate supporters.

In my country, supporters of Brexit are taking pot-shots at the civil service for allegedly resisting attempts to portray post-Brexit Britain as paradise. No wonder government workers in both countries are feeling a little insecure right now.

In Saudi Arabia, the challenges are different. Not so much a problem of bias. In an autocratic system, civil servants do and say what the government asks, or face the consequences.  More a matter of bloat. 70% of Saudis in employment work for the government. If that percentage was replicated in the UK, we would have 21 million public servants out of a total working population of around 30 million. The actual number is around 6 million.

So if they are to transform their economy into one that looks like those of the West, you could say that the Saudis have two choices: cut down on the number of government employees, or increase the number of Saudis working in the private sector, which is heavily populated by foreign labour. In fact they are trying to do both, and have been doing so for the past thirty years, though with limited success.

Something has to give, because the huge numbers of public employees are a massive financial burden on a country struggling to balance the books in an era of low oil and gas prices

With those factors in mind, here’s what I wrote about one particular aspect of the Saudi bureaucracy thirty years ago – the watchdog whose job it was to keep the bureaucrats on the straight and narrow:

Then (1987)

Some are born bureaucrats, others have bureaucracy thrust upon them. In Saudi Arabia, the profession of pen-pusher is an honourable one. Indeed, the swelling ranks of the desk-bound have been instrumental in boosting many a government department’s sagging Saudisation numbers.

So the Saudis swamp their offices with pen-pushers in order to boost the percentage of native employees to an acceptable level. But what to do with the throngs of workers with grand job titles and few responsibilities?

A clue lies in the fact that security passes at airports require a huge number of signatures for approval, and that forms these days come in quintuple sets. Upon each signature and each form, a job depends. Another reason for the multiplicity of forms and approval levels is that the bureaucracy doesn’t trust itself. Delegation is definitely not the norm.

A Public Control Board answerable exclusively and directly to the King, exists primarily to scare the living daylights out of the bureaucrats, and thereby curb some of the worst excesses of the subjects of its attention: waste, corruption and failure to adhere to procedures. In theory anyway.

It’s staffed by hungry investigators, many of them other Arab countries, including Egypt and Jordan, whose arrogance is matched only by their ignorance of the process of government. It spends millions of riyals inquiring into discrepancies in ministry accounts as minuscule as ten riyals. So deep and detailed is their probing that those who are targeted fear not only for their reputations, but those of their great-grandfathers. No stone is left unturned, except those that their masters prefer to lie undisturbed.

The result of these orgies of paper-chasing is not that corruption has been stamped out. That continues no more and no less. Major acts of malfeasance that could embarrass the wrong people are simply ignored or covered up. The Control Board has created cells in every department, whose main mission is to produce and store warehouses full of documents in preparation for the moment when it strikes like a scorpion lurking in the dust.

Since the blame for any discrepancies is usually, whenever feasible, shifted on to the broad shoulders of a foreign contractor, the contractor, not the bureaucrat ends up getting penalised, which the Control Board considers a satisfactory result. It isn’t of course, because most contractors factor such penalties into their original prices. With the result that in most cases the government is paying way more than it needs to.

Now (2018)

I was perhaps a little unkind about the work of what is now known as the Control and Investigation Board. Since the 80s they have done some important work, not least in bringing to justice some of those responsible for the shoddy civil engineering projects that contributed towards the catastrophic flooding of Jeddah in 2009.

That said, the warehouses full of paper diligently collected for fear of the watchdog’s scrutiny will have come in pretty useful last year, when Crown Prince Mohammed was preparing for his round-up of family members and eminent businessmen accused of siphoning off funds from government contracts over an extended period. The scorpion struck, but not where everybody expected.

As for the bureaucrats, no doubt they will still be quaking in their boots, not so much because of the bean counters scrutinising petty transactions, but for fear of an early morning visit from the Crown Prince who, like Sheikh Mohammed of Dubai, has acquired a reputation for surprise visits to government offices at times when no self-respecting civil servant would dream of being present. At 9am, for example.

The civil service has continued to grow since 1987, but two factors have slowed the hiring. First, more services are on-line, so less bureaucrats are required to service the lines of supplicants outside ministry offices. Second, the government has realised that it can no longer fund legions of civil servants with nothing to do all day except play with their smart phones.

So there have been concerted efforts to diversify the economy and encourage a more vigorous private sector that will hire more young Saudis, including women. Not an easy task when you take into account the natural inclination of business owners to hire large numbers of foreign staff who cost far less than it takes to provide young Saudis with a living wage.

The bureaucrats have a role to play in sorting out the conundrum of how to get the youth into work without damaging the competitiveness of the businesses they want to encourage. The tactics in recent years have been some carrots (subsidies for employment and training) and plenty of stick (less visas for foreign workers, levies on employment of foreigners, higher visa fees and wholesale deportation of illegal workers). All of which results – at least for the Ministry of Labor and its associated agencies – in more work for the working man (and occasionally, woman) to do.

The joys of being a bureaucrat continue to endure. Shorter working hours than in the private sector, which gives them plenty of time to run small businesses on the side. Social status and perceived job stability, which make it easier for them to marry their sons and daughters into other respectable families.

But as Mohammed bin Salman and his young western-educated cohorts tighten their grip on the mechanisms of government, the days of the cushy number might be coming to an end. Which, for many civil servants, might be no bad thing.

After all, what’s the point of spending the majority of your working life bored out of your skull?.

Winter Reading: Blitzed – Drugs in Nazi Germany

As a student of the Second World War, it was always a mystery to me why in 1940 the German armed forces, outnumbered by the combined forces of Britain and France, and with inferior equipment, managed to cut through France and reach the Channel with such devastating speed.

There have been many explanations, of course, ranging from the static tactics that the defenders inherited from the previous war to a lack of fighting spirit from two nations that suffered so grievously between 1914 and 1918.

The idea that the German invasion force was doped up on methamphetamine, from commanders such as Rommel and Guderian down to the tank crews that formed the spearhead of the advance – and thereby was able to sustain the attack for several days without sleep – is a new one to me.

That, though, is the theory put forward by the German writer Norman Ohler in his book Blitzed. He spends the early part of his narrative describing how in the 1930s Germany, deprived of natural resources by the loss of its colonies after the First World War, became expert in synthesising pain-killing and performance-enhancing drugs – cocaine, morphine and methamphetamine.

The latter was widely marketed as Pervitin. Whereas the Nazis saw cocaine and morphine as decadent drugs beloved by Jews and other undesirable elements, Pervitin seemed to be the wonder drug. It was available without prescription, and was used enthusiastically at all levels of German society – by housewives needing a lift, students preparing for exams and athletes competing in the 1936 Olympics.

Army commanders in a number of units fed the drug to their troops during the invasion of Poland, though not systematically. The results, in terms of alertness, aggression and endurance, convinced the High Command to sanction the use of Pervitin by all units, including the air force, in the forthcoming invasion of France and Belgium. They ordered huge quantities of the drug, ignoring the dangerous consequences of overdose, as well as the debilitating exhaustion that eventually caught up with users.

The invasion force rampaged through France at lightening speed. Tank crews were able to press onwards for three days without sleep. The British and the French were stunned by the speed of the advance. They were constantly on the back foot, unable to catch up.

In one passage, Ohner describes Rommel blasting through French units:

He (Rommel) had no apparent sense of danger – a typical symptom of excessive methamphetamine consumption. Even in the middle of the night, he stormed on and attacked solid positions while still in motion, firing all barrels like a sort of berserker, constantly catching his adversaries on the back foot. The French despaired at the sight of the unleashed monsters coming at full speed towards their artillery. What on earth were they supposed to do? There were no instructions on how to defend yourself in that situation; they’d never practiced it in manoeuvres.

Towards the end of that first week of the attack there was a ghostly scene that casts a sharp light on the German advance: in the early hours of 17 May 1940, Rommel, no longer answerable to any of his superiors, tore along the road from Solre-le-Château, right in the north of France, towards Avesnes. As chance would have it, the 5th Infantry Division, parts of the 18th Infantry Division and the 1st Infantry Division of the French Army had struck their bivouac on that very spot. Rommel didn’t hesitate for a second. He dashed through them, crushing everyone and everything, fired broadsides, and over the next ten kilometres he pushed hundreds of vehicles and tanks, along with the dead and wounded, into the ditches on either side and rattled on with blood-smeared tracks, standing between two officers from his staff in the armoured command post vehicle, his cap pushed to the back of his head, leading the attack.

Drugs, Ohner believes, also played their part in letting the British off the hook at Dunkirk. Guderian was ready to wipe out the encircled British and French forces, when he received the order from Hitler to halt. It seems that Goering, a morphine addict, persuaded Hitler to let the Luftwaffe finish off the campaign form the air. Both saw the army with its Prussian military ethos as potentially disloyal. The Luftwaffe, on the other hand, was a Nazi creation. Best that they should have the honour of delivering the coup de grace.

Except that they failed to do so. Over ten days, as Guderian and his tank divisions looked on, the British and a number of French units were evacuated from the beaches. Was Goering pumped up into a grand delusion by the morphine flowing in his veins? That’s certainly Ohner’s theory.

I’m always interested to encounter German perspectives on the Second World War. One of my favourite movies about the war was Downfall, which depicted Hitler’s secretary’s account of the Fuhrer’s last few days in his Berlin Bunker. It was lit up by a magnificent performance from Bruno Ganz as a raging, deluded, self-pitying leader as he descended into his self-created hell.

As Norman Ohner relates Hitler’s drug dependence, starting with the bizarre injections administered by his doctor, Theodor Morell, and ending in almost complete physical collapse as he became increasingly dependent on opiods, cocaine, vitamins and untested hormones derived from animal organs, Ganz’s portrayal seems more faithful to his subject than ever.

Dr Morell became the Fuhrer’s his shadow, never allowed to leave his side, always ready with a battery of syringes and concoctions to revive the Fuhrer when needed, which was usually every day. Morell himself became wealthy through hawking his treatments around the Nazi leadership, and eventually by massive sales of vitamins to the armed forces.

Using archives in the US and Germany, Ohner plots in painful detail Hitler’s increasing reliance on Morell’s treatments from 1936, when they first met, until the last days in 1945. Morell was short, fat, vain and ambitious, toadying to his master and arrogant to others, as is so often the case with an autocrat’s courtiers.

As I read the story of the Fuhrer’s slow decline, Bruno Ganz’s performance kept coming back to me, especially as Ohner describes Hitler in his terminal state, hand and leg shaking uncontrollably, with track marks caused by incessant injections, drooling at the mouth, with food stains on his clothing. The picture on the cover of the book shows him in June 1944 around the time of Valkyrie assassination attempt, bug-eyed and stooping, hardly a picture of vigour.

Until just before the end Hitler was pathetically grateful to Morell for his treatments, claiming that the doctor had saved his life on several occasions. A few days before the end, Hitler dismissed him, enraged because Morrell couldn’t get his hands on the usual medications. The doctor managed to get out of Berlin, and was captured by the Americans, whose interrogators found him too drug-addled to provide them with any meaningful information. Two years later they dumped him, penniless at Munich Station, and, after being rescued – ironically – by a half Jewish Red Cross nurse, he died in hospital a few months later of chronic heart disease.

Blitzed is Norman Ohner’s first work of non-fiction. It’s gripping and fast-paced, and infused with plenty of black humour.

Until I heard about the book a couple of years ago, I was under the impression that the major pharmacological advance of the Second World War was the discovery of penicillin, which saved thousands of lives of servicemen who in earlier times would have died from infected wounds.

The Nazi use of methamphetamine was almost as significant. It echoes to this day. Various drugs, including amphetamines and marijuana, were used without official sanction during the Vietnam War. More recently, ISIS fighters have been prolific users of captagon, another form of amphetamine. Did that explain how ISIS marched into Mosul against overwhelming odds? Shades, perhaps of the German blitzkrieg in France.

The extent to which other armies use performance-enhancing drugs is not widely known, but it would not be surprising if the Americans, Russians and Chinese are not experimenting with a new generation of drugs that enhance resilience and cognition.

One thing’s for sure. Until such time as all the fighting is done by robots, humans required to risk their lives on the battlefield will always find it hard to refuse a chemical helping hand, be it in the form of a mug of rum before facing the machine guns at the Somme, or a wonder pill to turn them into supermen in the face of overwhelming force.

I can’t say I blame them, though the thought of submarine captains, drone pilots and those who man missile silos off their heads at critical moments is profoundly disturbing. And the same goes for presidents of the United States.

Winter Reading – Terms and Conditions: Life in Girls’ Boarding Schools 1939-1979

When I was a boy, I used to wonder why my mother was slightly, well, odd. Not odd as in mentally unstable, or even eccentric. Just different from the mothers of my friends, who used to radiate confidence in social situations, parties and school events. She dreaded them because she felt “one down”. Visits from my friends were tolerated, not embraced.

There was a low hum of melancholy that persisted in her throughout the good times as well as the bad. Of the latter, there were many. On rainy days, she would, in the words of my younger brother, be “depressed of the weather”.

I used to think that her low-key personality, her lack of joie de vivre, arose from an insecurity as a result of my father’s career, which flourished for the first years of their married life, and then came crashing down, largely because of some reckless business decisions.

As I grew up, I came to realise that that her melancholia ran much deeper, back to childhood.  Her father died young, and her mother married again. She always felt that her mother preferred male company and wanted to enjoy her second marriage without the inconvenient presence of a female rival for the attention of the new man in her life.

So my grandmother packed her off to a boarding school, selected, sight unseen, on the recommendation of a friend. My mother didn’t speak much about it, except that it didn’t provide her with much of an education. Fortunately, for the last two years of her schooling, she went to live with my great aunt, a teacher, and attended as a day pupil an excellent church school.

Her brother, in contrast, went to a boy’s boarding school, from where he went to Oxford, en route to a watery grave at the hands of a German U-boat.

I didn’t think too much about the effect on her of the boarding school to which she was dispatched, a hundred and fifty miles from home, and which my grandmother never visited.

Then I read a remarkable book that made me realise that her years away from home might have responsible for her innate sadness and lack of confidence in later life.

The book is Terms and Conditions: Life in Girls’ Boarding Schools 1939-1979, by Ysenda Maxtone Graham. I bought it the other day on a whim, thinking that it might be an interesting counterpoint to my experience as a school boarder, which lasted from the age of eight to seventeen.

My school days were relatively benign, perhaps because my parents went to great lengths to select institutions where they thought my brothers and I would flourish. They discounted any schools that used corporal punishment, interviewed the headmasters and took an interest in every aspect of the education and wider experience that the schools offered.

My sister, on the other hand, didn’t go to boarding school, but ended up at the same day school as my mother, where she excelled. If she still feels that she drew the short straw, as I believe she did at the time, Maxtone Graham’s book might convince her otherwise.

The author interviewed dozens of former pupils of British girls’ schools that to a greater or lesser extent flourished from the end of the 19th through to the late 20th centuries, after which many were wiped out by the decision of cash-strapped boy’s schools to go co-educational.

The stories her interviewees tell range from hilarious to horrifying. The worst of the schools were ghastly. Cold, loveless places ran by vindictive, opinionated, unmarried women who cared less for the welfare and development of those in their care than for the maintenance of order and routine.

Draughty former country houses, linoleum floors, the pervasive smell of cauliflower. Dormitories so cold that hot water bottles froze. Sadistic teachers who delighted in belittling their charges, and who knew precious little about the subjects they were supposed to teach. An obsession with “games” – netball, cricket, hockey and lacrosse, to be endured whatever the weather. Pupils weeping with homesickness, some of them sent away at the age of four by their parents in India, not to see them again for a year.

For all but a few elite schools, the objective of the “education” provided was the prepare their pupils for a life of marriage and motherhood. They would be taught deportment, domestic skills and a modicum of conventional subjects such as English, French and Maths. Precious little science.

The trajectory for these girls from middle and upper-class families was finishing school, a secretarial job at the Foreign Office or Sotheby’s followed by marriage to Mr Right, who would be a doctor, a lawyer, a diplomat or a member of the landed gentry. Or, better still, a peer of the realm with a large estate.

University? Not possible with the education they received. Those who had such aspirations found them knocked swiftly on the head by fathers who believed that careers were not for their daughters. Princess Diana was a product of such a school. She left without a single qualification, and on occasion would refer to herself as thick. Subsequent history, I think, showed that she was far from stupid.

Not all schools were such hellholes of mediocrity, but many were. There would be the occasional chinks of light – inspiring teachers who left their pupils with a lifelong love for poetry, Shakespeare and art. And in amongst the indifference or sadism of the staff, kindness and compassion.

Yet despite their horror stories, many of those who contributed to the book talk of happiness and the life-long friendships they made. Of the joy of roaming the grounds of the grand country houses where the schools were located. During the Second World War, some relocated to country seats still in the possession of aristocratic families – Chatsworth and Castle Howard, for example. Some, now in their eighties, have magical memories of those places.

Aside from the grim mediocrity of so many of the institutions, there were the convents, ran by nuns who again varied from cruel to nurturing. And then there were the academic schools, Cheltenham Ladies College, Roedean, Badminton and Benenden, whose main purpose was to churn out Oxbridge candidates through regimes of iron discipline and intellectual rigour. Unlike the others, for whom a pupil gaining admission to university was in one case cause for a plaque on the wall in gold leaf, these schools were spectacularly successful.

But I don’t get the impression that they were places of joy. And more or less across the board, bullying among pupils could be vicious and sustained. As an example:

At Downe House in the early 1950s the classroom called 4B was ‘the divorce classroom’. It had doors on each side, which made it ideal for the purpose. When a clique decided they didn’t want to be friends with you any more there was a formal divorce process, and it all took place in 4B. The 13-year-old Amanda Theunissen was formally divorced in this way. ‘I suddenly found that the other girls weren’t laughing at my jokes any more. That was the warning sign. This was how the divorce process worked: you were called down to 4B. A you came in through one door, all the girls who had been your friends walked out through the other. That was it.  From that moment on you were an outcast. You were allowed to go around with the one disabled girl and the two foreigners who weren’t princesses’

Amanda has never felt as utterly unprotected as she did at that moment. There was no one to appeal to. The story makes us weep, not only for Amanda, but also for the disabled girl – ‘she had something wrong with her arm, and greasy hair, and wore thick round glasses’, Amanda said – and for the non-royal foreign girls, who had never been invited into the clique. Their loneliness and homesickness can only be imagined.

As anyone who has daughters will know, girls are capable of unspeakable cruelty without having to lay a finger on their victims.

Maxtone Graham finishes the book by observing that for all the awfulness, discomfort and emotional deprivation, women emerged from the experience with resilience, stoicism and a sense of duty and social responsibility, as well as loyalty to the life-long friends they made. Somehow, she says, they managed to transcend the emotionally buttoned up-culture that afflicted their counterparts in the boy’s schools.

She says that she can recognise one of their breed just by looking at them and talking to them. I think I can too, both in my mother’s friends, now departed, and in a few of my contemporaries.

Which brings me back to my mother. She was a product of that system. She was an intelligent woman who today might have gone to university and forged a career. She was widely read, a lover of the theatre, of nature and of animals. She had impeccable manners. She knew how to cook, sew, lay a table and ask for the salt. But how much more could she have achieved with an education that encouraged her to dream?

As things turned out, she met my father, a lawyer, and raised four children. Her only “proper job” was serving in the WRENS (the Women’s Royal Naval Service) during the Second World War.

Looking back now, three years after her death at 94, I wonder whether she was one of the bullied ones. Someone whose confidence was wrecked by an experience like that of Angela Theunisson, or perhaps by many similar tribulations. By exclusion, mockery and cruel practical jokes. Perhaps also, like other girls from families of relatively modest means, she was looked down on because of her perceived low social status.

I’ll never know. But if I’d read Terms and Conditions before she died, I would have asked her more about her school days. Losing a father when young, and then a brother during the war, and being – as she must have seen it – packed away, can’t have been easy. Though perhaps not unbearable enough to induce a lifetime’s melancholia.

But thanks to Ysenda Maxtone Graham and her contributors, I have a strong sense that I’ve found the last piece in the jigsaw of her life.

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