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The COVID-19 pandemic has started to pose questions that my biomedical training can’t answer. As an internist working full-time in a quaternary-care academic hospital, I have an inbox filled with bulletins about Sars-CoV-2, the causative virus of the disease COVID-19. Last week, I pulled my copy of Philip Roth’s Nemesis from my shelf. I first read the book in 2014 as a student, sneaking it into my schedule, guilty with the pleasure of reading but not reading about medicine.
Why Nemesis? Primum non nocere. First, do no harm. Medical students across the country recite some form of the Hippocratic oath every year. A dictum from antiquity that guides modern medical ethics. My patients often face myriad harms, and the dictum is often on my mind. But what if I’m doing harm, and I don’t know it? Enter Bucky Cantor.
Spoilers ahead. P.E. teacher and former high-school track star Bucky Cantor spreads Polio throughout a Jewish community of schoolchildren in 1944 Newark and, later, a summer camp in the Poconos. He is the ideal vector because he is initially asymptomatic. Only when a precautionary lumbar puncture confirms the presence of the virus does he realize he has been an agent of pestilence. The novel’s narrator, Arnie, is one of the “Chancellor Avenue playground boys” who contracted the disease from his cherished teacher Bucky. A chance encounter in adulthood leads them to reconnect and strike up an uneasy friendship. Decades after the infection, Bucky has become quite miserable. He has spurned his long-lost love (Marcia, the girlfriend who drew him to the Poconos) and sought out a solitary life, as if to atone for the harm his mere presence once wrought.
The men discuss the damage the virus dealt their bodies. Bucky’s left arm is paralyzed, and his legs are becoming weaker, likely soon requiring a wheelchair. Arnie’s legs are weak, but he is mobile with crutch and cane. Their exchange prompts Arnie to psychoanalyze his fallen childhood idol:
[Bucky] has to convert tragedy into guilt. He has to find a necessity for what happens. There is an epidemic and he needs a reason for it. He has to ask why. Why? Why? That it is pointless, contingent, preposterous, and tragic will not satisfy him. That it is a proliferating virus will not satisfy him. Instead he looks desperately for a deeper cause, this martyr, this maniac of the why, and finds the why either in God or in himself, or mystically, mysteriously, in their dreadful joining together as the sole destroyer (265).
The passage is Arnie’s secular indictment of the pitfalls of guilt. According to Arnie, to be a maniac of the Why, you corner yourself into perpetual self-blame or you begrudge the Creator for being inherently punitive. Or both. But neither gets you anywhere. Arnie attributes his own good life to luck — he met his wife, and he “got weaned away from railing at my fate.” As a reader, it is hard not to side with Arnie, the thoughtful, pragmatic founder of a successful architecture firm specializing in wheelchair-accessible modifications. He is living proof: things happen, but one should try to move on.
How would I react if my mere presence became harmful? It is not a purely theoretical question. As I write this, the state of Virginia has fifty test kits for COVID-19. Last week alone, I was worried enough about five of my patients to test them for other respiratory viruses. If I could have, I also would have tested them for Sars-CoV-2. Following guidelines issued by Virginia’s Health Department, Hospital Epidemiology can order testing only when a patient meets criteria that are at once strict and ever-changing. The official designation “Person Under Investigation” earns a test. Otherwise, people go untested, even if their clinical picture suggests they could have the disease.
In a time of dramatically limited diagnostic testing, my co-workers and I are poised to be ideal vectors. Cases from across the world have demonstrated that asymptomatic hosts spread the virus. The unwitting doctor transmitting Sars- CoV-2 is a modern-day Typhoid Mary, a Bucky Cantor had he been clinician and not P.E. teacher. Each day, I try not to imagine what would happen if the virus finds its way to me. Whether I have a tickle in my throat, whether I feel a little winded, whether it is all because pollen output is climbing during our abnormally warm spring, or whether I am entirely asymptomatic, I will carry on treating the people under my care as is expected. My patients take immunosuppressives for transplanted kidneys. They have diabetes and stenotic coronaries and obstructive lung disease. They have cancer. And so on. To sow COVID-19 among them would undoubtedly bring them harm.
There are many ways our response could be better. Solutions are conceptually simple and logistically baffling. Such as: all clinicians wear masks. (They’re on shortage.) All patients presenting with respiratory symptoms are automatically tested and wear masks in the meantime. (We have no tests; masks are on shortage.) Cancel plans. Hunker in place. Work from home. Some countries like South Korea are reporting lower mortality rates, which are likely correlated with such practices. At our hospital, the wheels for a better plan are in motion. Some variation of early testing is where we are headed. It is no small undertaking.
In the meantime, my co-workers and I grapple with uncertainty in our own private ways. Some of us put it out of our minds. Some of us exhaustively research new studies, compile the results, update the group. Some of us read fiction.
As a doctor, what can I learn from Nemesis? When I discuss literature with medical students and residents in a course offered to trainees in their final years, the question — why should clinicians read literature? — if not overtly raised, always looms in the pedagogical foreground. It is not a popular question. It might be a boring question. Why should we eat this kale? Most of us already know the answer. It’s good for us. The studies are salient, if not statistically overwhelming: literary fiction requires the reader to wrestle with complicated human circumstances, sharpening empathy in the process. Like shooting free throws, engaging with art exercises a useful muscle, but it is not the main reason most of us entered the gym. The utility of reading literature has become so well- established in undergraduate medical education that most residents in our program, by the time we sit down to talk about a short story, have already studied some form of art in a classroom.
Why read literature at all? Who sits down with a novel in order to become a better person? Arguing for the utilitarian function of art has always struck me as a scolding deformation of a joyful thing. Why else do we skip over great books in high school only to rediscover them later in life? Aren’t fresh vegetables, even kale, when picked from the garden, some of the best things to eat? Until we’re told we have to? Can reading just be fun? If a random force of nature like Sars- CoV-2 is bearing down on us, it seems fitting to tackle it with the illogical practice of reading fiction. Fiction requires us to sit with mystery. Fiction does not ask us for answers. We permit ourselves to reject Bucky’s rallying cry for logic where none exists.
The practice of medicine demands answers, yet to practice medicine in the United States is an invitation to become post-Polio Bucky, to be swallowed by suffering that eludes meaning. In my daily working life, I frequently observe the collision of biological misfortune and human cruelty. One example: random misfortune gives my patient blood cancer. Human cruelty, or at best, indifference, in the form of the inflexible rules of insurance, drives her to sell her house in order to purchase chemotherapy. Where is the meaning here? When she was my patient, I became the maniac of the Why. Now, as cases of COVID-19 in Virginia jump from ten to seventeen, more questions come. Will the virus follow the example set by other diseases, disproportionately affecting the poor, the uninsured, the victims of structural violence and racism, the people set up by the system to fail? (Of course.) Why are “social determinants of health” often more predictive of a person’s fate than the biological properties of the diseases they carry? Why can’t we just call “social determinants of health” by their other name — money? Why is there still so little affordable housing in a wealthy college town where new hotels and restaurants spring up every month? Why did schools in Virginia prefer to close than abide the mandate of Brown v. Board of Education? The line of questioning has no end.
It’s all a little too much. Jewish-American children dying of Polio is a tragedy of biology nestled within the staggering human-made tragedy of the Holocaust. Even so, Roth knows better than to end the book on a note of pure doom. In the final scene, Bucky shows his students how to throw a javelin. He first puts on a display of proper stretching. He lunges, squats, and even walks around on his hands. Finally, “he finished off with forward body bends and trunk back-bends, during which he kept his heels fixed to the ground while pushing upward with his hip and arching his back amazingly high.” Of all the words at Roth’s disposal, why use amazing? Bland and ubiquitous in everyday speech, here it is most consistent with the fourth entry in the Oxford English Dictionary: “To overwhelm with wonder.” Bucky’s body is an object of wonder, but not pathologized wonder as it will later appear to him. The javelin flies again and again through the air. The children cheer. In drawing out Bucky’s achievement through Arnie’s nostalgic lens, Roth depicts a moment of goodness that is so pure, it is destined to become the stuff of legend. It is a poignant end of the novel, and even more poignant as the last fiction of Roth’s life, as if the writer is saying: yes, this is all temporary and doomed, but isn’t it great anyways?
Until widespread testing becomes available, there is no way to know if the virus lives in me or if it doesn’t. But if I’m going to worry about it, I should also take the time to enjoy everything it imperils. So I go for a run. I am no Bucky Cantor, but I do my best. I enjoy the breeze and the smell of the thawing earth. I survey the great trees growing throughout town. An American Elm stands in front of my home. It is covered in green vine. The branches are tortuous. They remind me of the meandering estuaries of coastal New England, the scenery of my childhood. Entropy may be driving us toward dissolution, but for now, there are familiar shapes everywhere we look. Like Bucky launching the javelin into the air, these are small pleasures, but they are real ones.
Copyright 2020 Ben Martin
Ben Martin is an assistant professor of Internal Medicine at the University of Virginia. Before medical school, he received his BA in creative writing from Middlebury College, where his senior thesis, a novella, received the annual D.E. Axinn Prize for Creative Writing.