Monday, 25 June 2018

Flodden, an unexpected symbol of friendship

This ground, known as Flodden Field, was once a field of battle, enmity and carnage. But today, there is the spirit of reconciliation, co-operation and, above all friendship.

So run the words on the information board erected at the bottom of the path which leads up to the Flodden Field memorial. I was taken aback. I really hadn't expected anything like that. I thought this site would be the English counterpart of Bannockburn.

Stuart hadn't wanted to visit Flodden. In his words, it was because 'the Scots had made an arse of it'. I wanted to visit, however, because a friend had told me what a moving experience she had found it. Stuart is being nice to me these days because I've been ill, so we went.

Flodden Field lies above the village of Branxton, on the English side of the border between England and Scotland. And for most English people, who almost certainly have no idea what happened here, and for others from across the world who make up the majority of this blog's readers, it is probably necessary to explain the events of which, for a day or two,  this tiny hamlet was at the centre. Scots, of course, or at least Scots who know a bit of history, are only too well aware of these events and quite a few of them, like Stuart, don't really want to be reminded.

So, here goes, in a nutshell. Scots can skip over the next bit.

In 1513, King Henry VIII, the English king, was at war with France, as part of the War of the League of Cambrai - a war between the mainland European powers. King James IV of Scotland, which was allied to France under the Auld Alliance planned to attack the English in order to divert Henry away from the French. Henry had asked James to join the English side. They were, after all, brothers-in-law for James' wife Margaret was Henry's sister. James refused. For this breach of his peace treaties with England, James was excommunicated. So far, so complicated - but it gets worse.

James sent advance notice to the English of his intention to invade in a month's time, as one did in the Middle Ages, apparently. That gave Catherine of Aragon, Henry's wife and Regent while he was in France, time to raise another army and collect the banner of St Cuthbert from Durham Cathedral. That banner had led the English to success in previous battles.

James invaded England, as he had said he would. He took up a strong position on Branxton Hill, and then, unwisely, launched an attack on the English downhill and across marshy ground. Historians have pointed to the old-fashioned Scottish weaponry, the pike, as ill-suited to that kind of attack, and to the fact that the Scots placed their officers in the front line, as among the other reasons for the disaster that followed. James was killed and with him the 'flower' of the Scots nobility.

As the Branxton board puts it:

On that fateful day, near five hundred years ago, it was the hills, the valleys, the rivers, the streams, the hidden denes, the boggy ground, that were the key to victory. It was here, where today cattle graze and crops flourish, that cannonade crashed and men fought and died.

Ballad makers on both sides of the border sang of the losses at Flodden Field for centuries after. Here is a stanza from the lovely Scots lament, Flowers of the Forest.

We'll hae nae mair lilting, at the yowe-milking,
Women and bairns are dowie and wae.
Sighing and moaning, on ilka green loaning,
The flowers of the forest are all wede away.

After the battle and its terrible losses, the Scots expected the English to invade. Indeed,  the people of Edinburgh threw up a city wall, still called the Flodden Wall, to protect them from attack. In fact, the English made no attempt to invade Scotland,  despite its vulnerability under its infant king.  King James V, son of James IV,  was only 17 months old when he was crowned, immediately after news of the defeat reached Stirling Castle, where Queen Margaret had anxiously been waiting to hear of the outcome of the battle.

You might expect the English to regard their victory over the Scots at Flodden with a similar triumphalism to that of the Scots who still consider their victory at Bannockburn in 1314 as the defining humiliation of their hated English foe.

Far from it. While the Scots still sing of Bannockburn at every sporting event and nationalist demonstration, particularly when confronting the English, the English have long forgotten their victory at Flodden. They certainly don't sing about it every time they face the Scots across the rugby pitch or recall it when they want to be particularly insulting to a hapless representative of their historic enemy, as happened to me only two days ago.

Back to the Branxton noticeboard.

It was here, on the quiet byroads and deserted tracks, that opposing armies once trod. And it is here, that this story of success and despair should be told.

For, at Branxton, there is no National Trust or English Heritage visitor centre. How different from Bannockburn. Indeed, no stirring account of the victors' triumph and the crushing of the defeated is inscribed indelibly into the national psyche of the English. Remembering has, instead, been left to the villagers of Branxton. And this is what they say.

Branxton is the small village that encompasses this hugely important and yet relatively unknown historical site. We hope that our efforts will inform and educate, and bring visitors to this part of the Borderlands, and help consolidate the bonds of friendship across the Border that are today, the hallmarks of life hereabouts.

I would love to say that I have seen a sign like that in Scotland about the English, a sign that celebrated a 'spirit of reconciliation, co-operation and, above all friendship', but there, I haven't.

In fact, Scotland was never conquered by England, contrary to popular belief. However, less than a hundred years after Flodden, it was the Scottish King, James VI, James IV's grandson, who in 1603 set in train the eventual union between the two countries. Inheriting the English throne from the Tudor Queen Elizabeth, the last of that Anglo-Welsh dynasty, he brought about the Union of the Crowns. His descendants, the Scottish royal family called the Stuarts, ruled England for the next hundred years.

And so we now have a United Kingdom, thanks to James VI and the Scots.

Sunday, 3 June 2018

Picking up the threads after chemo

It's time to get back to where I was. No, that's not quite right, as no one can ever get back to where they were, particularly if the previous few months have turned one's life upside down.

No, it's more like picking up the threads, and weaving them into something quite different from the diagram on the pattern one believed one was following. I had thought I knew exactly what life had in store for me. A year ago, I was expecting just a few more journeys to Malawi to complete my work. More importantly, I was also looking forward to some real travelling, for interesting and beautiful though Malawi is, I spend most of my time in the office or on the road. Worthwhile though my work is, it has also had significant opportunity costs. Among these costs has been time to explore the rest of the world. I had been looking forward to making up for it by embarking on journeys to a range of exotic and far-flung destinations.

Ah well, some mischievous sprite must have been listening to my ruminations, for even these tentative plans to see the world collapsed. I haven't travelled anywhere for months, for the medical reasons set out in my earlier post Thank you, Scotland's NHS.  There has been no visit to Ethiopia, nor to any of the regions of India. I haven't visited Namibia nor the Tanzanian savannah. South-east Asia remains completely unfamiliar, as are central and southern America. I've never been to Russia. So many places to visit and so little time. While I have been frequenting the Edinburgh Cancer Centre, my friends have been exploring the world. Despite living vicariously through their Facebook posts, I must admit to twinges of envy.

I have been fortunate. Mine was one of the most common cancers and has been caught early. In fact, a few years ago, I would simply have undergone surgery and radiotherapy. The prognosis would still have been very good.

However, like most women these days I was also offered chemotherapy which would, I was told, add an extra 5% to my chance of surviving into old age. And I accepted. Whether this was the right decision, I am now not so sure.

Everyone knows that chemotherapy can cause nausea and sickness. We all know that you are likely to lose your hair, and not just on your head either. These side effects were, in my case, the least of the problems. Medical staff control sickness quite successfully. A bald head is upsetting, but not painful, though lack of eye lashes results in sore and constantly weeping eyes. You don’t feel great, but, nevertheless, you can soldier through side effects like these. (Rapunzel, Rapunzel, let down your hair)

And not all people suffer all possible side effects. The drugs used may differ for different people. Some drugs are particularly harsh.

No, the side effects which really made me wonder if it was all worthwhile were those I was not warned about. It is only recently that I have started to google them. These side effects have included agonising pain in the marrow of every single bone and every single tooth, terrible mouth sores and desperate exhaustion which sometimes made it difficult to climb the stairs to bed, let alone the three flights to the flat itself. My eyesight developed problems which made writing and driving difficult. My muscles still ache as if from some endless marathon, while the stinging sensation in my hands and feet are signs of damaged nerve endings, a temporary condition, I hope. Some potential side effects like damage to the heart can be serious. Damage to bones makes fractures more likely, despite ongoing treatment.  Drastically reduced white blood cells may result in dangerous infections, even sepsis, and require rapid hospitalisation.

The oncology department can mitigate most of these conditions, but not all of them, and not necessarily completely. In some people, the side effects may, apparently, persist to some degree for ever. Nevertheless, for patients with many other kinds of cancer such effects are clearly worth the pain and discomfort.

However, was the chemo worth it for me?

That is a difficult question to answer.

What if some of these side effects continue, as they may? That may put paid to any more serious foreign travel to unusual destinations. This ‘first world problem’ may sound like the whining of a spoilt child. I have, after all, benefited from the some of the most advanced treatment anywhere in the world.

However, there are a couple of other issues worth considering.

Firstly, I did not have an unusual or difficult-to-treat cancer. I think it is justifiable to ask whether losing a couple of years now, ‘losing’ as in experiencing a reduced quality of life during the active early years of retirement, is completely compensated for by having a couple of extra years of life in one’s late eighties. Over the last few months, I have scarcely seen my grandchildren, because of the risk of infection but also because I just wasn't up to it. I have largely missed the progress and milestones of the three youngest, and the sporting and other successes of the eldest. The disruption to these relationships has been difficult.

Secondly, there is the issue of how NHS funds are deployed. Now, don’t get me wrong, I am not ungrateful. I am aware that the treatment I was offered, an offer which I could, I suppose, have turned down, was proposed in good faith as providing the best possible long-term prognosis. After every three-weekly out-patient appointment and occasional unscheduled hospital visit, I would return home with at least one bag filled with remedies for the side effects of chemo – not just numerous anti-nausea tablets, but steroids, anti-fungals, anti-virals and anti-biotics. I received painkillers, of only moderate effectiveness, mouthwashes and eye drops. At one stage I was put on medication for my heart. All these remedies made things a bit better. However, what did they cost in financial terms, not just for me but for all the other women with early-stage breast cancer like mine?

Indeed, what did the chemo itself cost, not just the pharmaceuticals, but staff salaries and the organisational processes by which treatment is managed?

Excellent support systems like the Cancer Helpline provide telephone triage for those suffering serious side effects and organise immediate treatment if necessary. While the out-patient wards where routine chemotherapy is given run like clockwork, unscheduled visits to assessment clinics can reveal a system under severe stress. Hard-working staff convert out-patient cancer clinics into impromptu hospital wards for daytime and overnight care. After admission, I have waited five or six hours for a doctor, quite rightly when other patients suffer from far more serious conditions, but still upsetting and uncomfortable. Trolleys may be used instead of beds. I have observed patients in severe pain sit up on chairs for hours when not even trolleys were available. We may have had a bad winter, but surely weather does not affect cancer.

The question has to be asked: can we afford all this care for people like me?  I would quite probably have made a satisfactory recovery after lumpectomy and radiotherapy, with relatively few side effects and a quicker return to normal life.

In different contexts, other questions may also be asked.

Shortly before she died, Tessa Jowell called for increased research into the treatment of brain tumours. Her intervention raises questions about the relative neglect of less common cancers.

Recently in England, thousands of older women of a similar age to me, were found to have missed their final mammogram because of problems in the breast screening programme. Some are said to have shown symptoms of cancer.

These stories got me thinking about how comparatively well resourced primary breast cancer is. When caught early enough, the disease is to all intents and purposes survivable. The system grinds into action and patients like me work their way through various well-planned procedures.

The reaction of some well-respected oncologists to the breast screening debacle was interesting. They wrote that women who missed their final screening should not be overly concerned. They would be fine. In the west, routine screening may have led to over diagnosis and, perhaps, over-zealous treatment.

Might the money spent on chemo for people like me not be better spent on researching and developing treatment for more obscure tumours like Tessa Jowell’s or, indeed, not on cancer at all but on widespread and distressing conditions like dementia?

There is general acceptance that the health systems both north and south of the border are underfunded. One answer, rightly, is to decide whether to increase funding to meet the level of need. However, we also need a debate about whether in some circumstances some high-tech treatments are unnecessary or may not be worth the discomfort they result in.

Until now, I have not discussed this issue with anybody apart from Stuart and one or two close friends because I know how fortunate I am to have been diagnosed so early and to have received medical treatment of the highest quality.

And this is where my post finished yesterday evening, to be uploaded today.

At least, that was until I heard on the car radio that a major research study in the States had concluded that 70% of women with the most common early stage breast cancer did not benefit from chemotherapy.


Who knows whether the treatment I received was, strictly speaking, absolutely necessary? At the end of the day, good medical treatment depends on patients’ trust. It is for researchers and practitioners to follow the latest evidence and provide advice according to their professional judgement. I do not doubt for one minute that that was what happened in my case. If medical thinking has moved on, then that is all to the good, even if it is quite galling to consider that my chemo might not have been necessary after all.

All this is academic now. Best to move on, pick up the threads and get the most out of life, however different the pattern is turning out to be from the one I had in mind.