Levels of life

In the first of the three essays that make up Levels of Life, Julian Barnes quotes Félix Tournachon's 1863 pronouncement that the three supreme elements of modernity were ‘photography, electricity and aeronautics’. As Western societies age, our triptych might be grief, legacy and what comes after. In crowding out the idea of what comes after with a notion of annihilation, the more spirited atheists resemble the balloonists whom Barnes describes: from their privileged height they were moved to moral commentary. Grief and legacy therefore come into clearer focus. It is in his unstinting description of grief that Barnes makes a contribution which will be of interest to many geriatricians. Pat Kavanagh, his wife of 29 years, had also been Barnes' literary agent. She died at an age (62) that is younger and with a decline from a brain tumour that is quicker than what we typically see. Even so, his grief is unlikely to be any less deep than that felt by the spouses of our patients, although we rarely encounter a description as articulate as this. Such is the relentlessness of the exponential increase of mortality with age that, even in their eighth decade, many of our patients will have witnessed the death of an alarming number of their friends. By their 10th decade, most will be in only a small minority of survivors of their cohort. How they cope can have a determining influence on their own health, and how we treat them influences how they cope. Barnes paints a picture of searing grief. He shares many uncommon intimacies. For example, what ‘defines the lostness of the griefstruck’ is the need to tell the one who has died what has happened: ‘You constantly report things, so that the loved one ‘knows'’. This is a recurring theme: ‘This is what those who haven't crossed the tropic of grief often fail to understand: the fact that someone is dead may mean that they are not alive, but it does not mean that they do not exist. So I talked to her constantly’. Barnes is aware that he is traversing uncertain territory here. ‘Banal domestic issues are lightened by a brief discussion: she confirms that the bath mat is a disgrace and should be thrown away. Outsiders might find this eccentric, or even ‘morbid’ or self deceiving, habit; but outsiders are by definition those who have not known grief’. Barnes does not let this go. He persists. He wants to explain. He feels that we need to know what this is like, and he needs to tell us. ‘Though she always answers when I talk to her, there are limits to my ventriloquism. I can remember – or imagine – what she will say about something that has happened before, or is being closely repeated. But I cannot voice her reaction to new events’. No doubt different readers will react to different passages differently. Many long married couples will recognize an almost secret language in a set of references that mean much to them, but would be impenetrable to an outsider. Single words or phrases can evoke a range of memories and emotions. For them, Barnes' description of the loss of a shared vocabulary will be especially poignant. For my part, having spent so much time thinking about the accumulation of deficits as a proxy measure of aging, I was struck by this description: ‘Grief is a negative image of love, and if there can be the accumulation of love over the years then why not of grief’. Barnes has advice for all of us, whether as physician or as friend. He describes with barely suppressed fury his attempts to bring up his wife in conversations, only to have his offerings spurned. He reminds us ‘You need your friends not just as friends, but also as corroborators’. The question of the need to counter annihilation, without the belief that something better is to come, manifests itself in unusual ways. Barnes tells us that ‘The question of suicide arrives early, and quite logically’ and its solution is an attempt to resist annihilation: ‘If she is alive at all, she is alive in my memory’. This need to counter the idea of annihilation is likely to be heard again, as those in the baby boomer generation age and die. The grief memoirs of Joan Didion (reviewed in 2012; 41: 820), Joyce Carol Oates and Calvin Trillin have each dealt with this. There will be no easy appeal to a great national narrative, or sense or shared virtue, as Drew Gilpin Faust described in ‘This Republic of Suffering’, her account of how America fashioned a national narrative after the appalling loss of young men during the Civil War. With no great narrative beyond the fact of existence and its loss, what will emerge? I expect we will hear a great deal about legacy in the years to come. For Barnes, part of his legacy will be not just the maintenance of memory of his wife, and thereby of himself, but of this attempt to make grief real for those who have yet to feel its grip. Especially for those who live in the territories of death this book offers a key to an empathetic understanding with which we can be better doctors, and friends, to the grief struck among us.

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