The human side
SAMANTH SUBRAMANIAN
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An absorbing sequence of case studies that are shrewdly extrapolated to make larger points.
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Better; Dr. Atul Gawande, Metropolitan Books, $24.00
ONE of Jerome K. Jerome's Three Men, before he got In A Boat, best illustrates why the field of medicine endlessly fascinates us. Dipping into a medical dictionary to look something up, he is soon riveted by descriptions of diseases and symptoms. He is convinced that he has scarlet fever, cholera, diphtheria, gout and zymosis, and he takes it as a personal affront that the only ailment of which he exhibits no signs is housemaid's knee. A bubble of curiosity balloons rapidly into full-blown self-obsession. Therein lies the key: We are endlessly fascinated by medicine because we are endlessly fascinated by ourselves.
Piquant balance
Why wouldn't we be, though? How can we resist us, these creatures of brittle bone, stringy muscle, messy blood and fragile craniums, cells and tissues that somehow, inexplicably, can add up to William Shakespeare and Raphael and M.S. Subbulakshmi? And by extension, how can we resist doctors and their craft? We submit completely to their mastery of bone, muscle, blood and craniums, all the while knowing that healing is often one fine scalpel-stroke away from maiming or killing. It's a piquant balance, and it's one that Atul Gawande weighs endlessly in Better, his second collection of essays.
Gawande put together his first book, Complications, in 2002, when he was a resident in surgery in Boston. At the time, he'd already been a New Yorker staff writer for some years, and many of his essays were published first in that magazine. Complications was largely an inward look at Gawande's world of patients and ailments, as well as a recollection of his first tentative steps in surgery. Even then, though, seeds of disquiet had begun to prickle Gawande's sense of his profession. "What you find when you get in close, however — close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes — is how messy, uncertain, and also surprising medicine turns out to be."
Five years later, those seeds have taken firmer root, and Better proves to be a more outward-looking collection. Divided into three sections — "Diligence," "Doing Right" and "Ingenuity" — the book examines the absolute necessity of those three virtues, and how they can determine medicine's place in our world.
Better is, in the best traditions of American non-fiction, an absorbing sequence of case studies that are shrewdly extrapolated to make larger points. In "The Mop-Up," Gawande rides along on a polio immunisation blitz in rural Karnataka, a small cog in a global machine that aims to eradicate a disease. If even one doctor or one healthcare worker were to slip up, Gawande realises, it would doom years of work and millions of dollars of patient investment.
Diligence is rarely sexy and often taken for granted, sometimes it can even be about as mundane an action as doctors washing up before an examination. In medicine, though, even that can make a difference between life and death. Ninety thousand Americans die every year from infections acquired in hospitals, Gawande tells us in "On Washing Hands," and the medical community has cast nets far and wide for a solution that will just get doctors to use their soap more.
Ethical dilemmas
This is the sort of thing Gawande does magnificently — slice open and dissect professional debates that are usually accessible only to practitioners, but that will still affect every one of us. In his section on "Doing Right," Gawande wrestles with America's creaking malpractice system and knotty medical insurance, and with the ethical dilemmas of doctors called in to assist with judicial executions.
Nowhere does he pretend to offer even a ghost of a solution, but that is not so much a flaw in his writing as a welcome acknowledgement of the daunting complexity of these issues. There will always be mistakes, and there will always be ethical dilemmas, Gawande points out, simply because medicine will always be about human beings treating human beings.
But that can be as much a reason to be thankful as to be pessimistic, as "Ingenuity" proves. In "The Score" and "The Bell Curve," Gawande examines how one woman made childbirth immeasurably safer, and how a hospital has achieved astonishingly high success rates at treating cystic fibrosis. There is diligence here too, of course, but there is also the all-too-human brilliance and mental application of individual doctors.
Innovative spirit
As there is in Uti and Nanded in Maharashtra, where Gawande's father hails from, and where Gawande spent weeks watching in wonder as public clinic doctors worked under severe time constraints, with minimum equipment, to fashion remarkable diagnoses and cures. They conducted examinations patiently and carefully, they cheerfully battled scarcity and grime, and they worked with what they had to create innovative surgical techniques that roused incredulity from Gawande's American colleagues — man's spirit and wits at their very best. In Complications, Gawande wrote about medicine: "The thing that startles me is how fundamentally human an endeavour it is." Better is not a regrettable admission of medicine's human nature but a thoughtful celebration of it.
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