| Book Review | Health and History, 7.2

Book Review

Changing Ways of Death in Twentieth-Century Australia. War, Medicine, and the Funeral Business. By Patricia Jalland (University of New South Wales Press, Sydney, 2006, pb, $39.95, ISBN 0-8684-0905-7) 371pp.

It is all too easy to assume that the longevity and health we now experience in the western world are the norm for humanity, which of course is not the case. Postcards from the past that challenge modern collective attempts at mastery of death are valuable. Historian Pat Jalland has made this field in Australia her own. In her first of two books, Australian Ways of Death (Oxford University Press, 2002), she traced early colonial Australian experiences of death and grief. In this one she continues the story up to the present day. She starts by looking through letters and diaries written during and after the two world wars, to show the immense ubiquitous pain of those conflicts in this country. Being born in postwar England, living for three years in Flanders as a boy, and having an Australian World War I veteran grandfather, I have never needed any persuading of the enormity of the all-pervasive impact of these wars on the late–twentieth century in the Anglo-Australian and western European worlds (to say nothing of the rest of the world).

Jalland argues that these awful wars gave rise to a progressive suppression of open communication about death and expression of grief, necessitated by the scale of loss and the need to survive (and win) the wars. This is coupled with the medicalisation and institutionalisation of death, as medical technology improves throughout the twentieth century and death and the process of dying move into hospitals and nursing homes. She then shows evidence of a recent movement towards a more open consideration of death, dying, loss, and grief—at least in the public domain ('...the second cultural shift of the late twentieth century, which has restored the option of more open emotional responses', p.37). She also rightly draws attention to the parallel emergence of the hospice and palliative care 'movement' and a rekindling of the old euthanasia debate as responses to suffering and loss in the death and dying process. Might they also be seen as different attempts at human mastery of death?

Rather like the recent film about Gallipoli (directed by Tolga Örnek) the author is particularly adept at taking a family's view of the losses, and picks up the narrative from the available material to construct a sense of scene setting, forward motion, and past reflection as the deaths and grief unfold. The account of Bill and Dallas Hayden's loss of a child in the 1960s is moving and instructive. He takes comfort from a conversation with a priest but cannot quite join him in prayer (p.36). He makes the important point that we do not recover from grief as such, and lives are never the same again and you never forget. This resonates with much modern sociological work such as Tony Walter in 'On Bereavement' where the medical model is challenged by the idea that we seek to reintegrate the loss into our changed lives, and this may lead to a persistent need to talk about the dead person that smacks of 'pathological' grief for those who have a more medical view of these things (which is probably a large part of our communities).

The West Australian author and communist Katharine Pritchard suffers the loss of her brother in World War I and her Victoria Cross decorated husband commits suicide in despair during the 1930s, writing on the back of his will that he never recovered from the 1914–1918 war. In a letter to her son she wrote: 'Almost everybody has had, or will have, some personal tragedy and though for the time being we can only do the best possible to survive our own, ultimately, you will know that your own sorrow unites you with the human stream.' This sense of restraint in the public expression of grief, because so many others have to endure their losses, is a pervasive one, and according to Jalland is at the heart of where things go wrong.

Jalland quotes Allan Kellehear about being careful to avoid the dangers, particularly cultural, of generalising the term death 'denial' when presenting five narratives drawn from the post-1918 era, in contrast with her earlier nineteenth-century research. These twentieth century stories are presented to show evidence of a culture of silence and restraint around grief and loss, and of avoidance of the reality of death that many would argue has been the hallmark of modern times, particularly since the appalling loses of World War I. Jalland also cites Beverley Raphael who talks of '[v]arious dimensions of death anxiety...: death avoidance, death fear, death denial, and reluctance to interact with the dying' (pp.20 et seq).

Modern medical practice in hospitals, and perhaps more surprisingly, in aged care facilities, is geared to keeping patients alive at all costs, and to doing everything possible to achieve this. The massive technical advances within medicine throughout the twentieth century have promoted the illusion, both within medicine and in the public mind, that death can be indefinitely postponed. To admit death is to admit defeat.

Palliative care teams become advocates for the recognition of natural death in the sense of acknowledgement of its imminence and inevitability, often in situations where heroic but futile and disproportionate treatment options are being offered to dying persons. The challenge is to bring about a transition in the goals of care to comfort and dignity rather than cure or length of survival. As a beginning to the process of equipping them to deal with these issues, I teach a class of first year medical students about historical aspects of death and dying. The (ambitious) intention is to inculcate them with a sense of historical perspective, that 'it has not always been so.' By seeing how recent it is for humans beings to have a reasonable expectation of living into their eighties in good health, I hope they will see that there comes a time when we are better off working with death than against it, and that we should be competent at relieving pain and suffering: physical, emotional, and spiritual.

Above all it is important to know that world views and prevailing social trends change, that religious preparation for death was the norm in the nineteenth century, that grief and bereavement conventions are largely socially determined, and that hiding from death is of no use as it finds us all anyway. Medicine can make a really positive contribution to the experience of death and dying, but it can also make it a misery if its practitioners do not recognise when to change gear. In this, and only this, we have some choice, and a bit of historical context might help. Novelist Betty Collins sums it all up well in a letter to Kylie Tennant, whose remarkable story is told at length: 'Our culture's attitude to dying creates these awful dependencies, and prolongs the process almost beyond endurance ... it's a good deal harder to die in Western society, both from a medical and spiritual point of view, than it is to get one's self born' (p.193).

No doubt there are those who would say that history of this sort is written by the articulate, that it tells us little of what it was really like for the masses, for those who could not write and reflect on their pain and that of others. But that is a history war and not a health war. Another favourite contemporary historian, Michael Ignatieff said he had a covenant with his readers. He laid out his work, the fruit of his research and then asked the reader simply 'is this true for you?' My answer is 'yes'; this book makes a lot of sense, and gives a plausible explanation of how we came to be where we are, and to appear to need specialist end of life doctors like myself. Every health worker should read it; in fact everyone should, because death is everybody's business. Unfortunately, as T.S. Eliot wrote, 'mankind cannot stand very much reality.'

Michael Ashby

St Vincent's Hospital, University of Melbourne

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