Francis, Gavin (2015) Adventures in Human Being, London: Profile Books.
Much praise has been lavished on ‘Adventures in Human Being’ by Gavin Francis, a multi-prize-winning best-seller admired by Hilary Mantel (who calls the book ‘sober and beautiful’), John Berger and Robin McKie.
And there is much to admire in this series of essays structured as an anatomy-tour of the human body running from top to tail via chest, abdomen, and pelvis. Francis writes about extraordinary (live donor kidney transplant surgery) and mundane (nausea and dizziness) medical moments and attends to medics and patients, human organs and social conditions alike. Looking back in time to Galen and Leonardo da Vinci, the writing creates alternative perspectives on persistent problems such as infertility and seizures. Attention is paid to place and space, from the tiny configurations of the inner ear to compelling description of the catacombs underlying Edinburgh University’s grand auditorium, where the author was a medical student. The desire to see human ills holistically and in the appropriate environment harks back to mediaeval traditions as well as Francis’ literary exploration of polar landscapes. The human interest of patient stories is maintained alongside references to poetry, biography, Greek and Tibetan medicine, exploring the dilemmas and uncertainties of the experience of illness through parallels, metaphors, and tangential explorations.
Francis attends to death, life and the liminal states in between, drawing on his experience as a general practitioner. Bill Dewart, a forty-a-day, 76-year old plumber, has inoperable lung cancer. An excursion around the anatomy of the lung, the trachea and the management of air pressure, leads to the dignity of Bill’s stoic rumination on the prospect of his own death while gazing at the city’s smoking crematorium chimney. Niamh, a gardener in a stately home, is a latter-day sleeping-beauty-cum-Snow-White, who gets scratched while weeding a rose bed, allowing staphylococcus bacteria to multiply in her blood. As she lays unconscious and intubated, Francis details the daily blood test results showing a failing liver, uncertain as to her prospects of recovery. This story has a happy ending with a long-estranged mother arriving at Niamh’s bedside to see her awake as her liver recovers. The book is impressive in maintaining a steady gaze upon medicine’s triumphs as well as failures: the lack of effective treatment for ‘unexplained fertility’ and profound depression; the limitations of the plumbing model to understand kidney function. Nor are the failings of healthcare professionals spared consideration: patients’ suffering compounded by insensitive clinicians’ routine questions; the woman in resuscitation who cried out ‘Help me doctor. I am dying,’ who could not be saved.
Unlike another medical best-selling author Henry Marsh, Francis does not berate himself over his own failings, perhaps because his personality does not intrude excessively upon the text. Francis notes dispassionately that medical training and progress are built on mistakes and reports that he turned his back a neurosurgery while still a trainee because he:
realised … that living with such responsibility is not just onerous, it utterly transforms the lives of those who bear it … As a trainee I realised that I had too many other interests to be a good neurosurgeon, and quit for emergency medicine – a tranquil backwater by comparison.
One of his other interests is listening, and the book is testament to Francis’ long-standing and ongoing ability to attend to his patients. The careful description of what he hears, sees and understands from this attention bears witness to the value of old fashioned General Practice, a theme he pursues elsewhere. Francis notes that not all clinicians are careful communicators, pointing to the difficulty of balancing empathy and compassion with the detached professionalism necessary to undertake work that is both taxing and demanding. He cites (page 84) Hilary Mantel’s less generous judgement that:
Nurses and doctors are an elite, self-selected as sufficiently insensitive to get on with the job.
What is missing from ‘Adventures in Human Being’ is the politics and economics of the clinical encounter. The absence of socio-economic context is not for want of analysis published elsewhere: Francis has written persuasively on the corrosive effects of private practice on general standards of care in the NHS and the role of poverty and education on health outcomes. But the socio-economic causes of patients’ troubles are mostly occluded in this book, with one exception. Francis makes a home visit to a woman dying of womb cancer and describes what he sees:
The TV took up more space than the fireplace, but no one was watching it. A two-bar electric fire glowed in the dark socket behind the hearth. An ashtray shaped like porcelain Pekingese dog was overflowing, and a confetti of cigarette butts littered the carpet. Along a line between the room’s entrance and the patient’s easy chair the carpet was worn thin; a trail greasy from the passage of dropped food and slippered feet. The sofa was longer than the room was wide, and seated on it were a man and a woman – the son and daughter of my patient. Both of them had to sit with knees splayed, to make room for the sag of their bellies. The son stood up to greet me, hand trembling.
This careful attention to squalor and the physical inadequacies of the woman’s offspring strike a discordant note in a book that otherwise offers even-handed description, avoiding moral judgement.
In wondering at the human body in sickness and in health, this book draws on poets, cultural critics and story-tellers. But what does citation of the articulate, aesthetic and lyrical to illuminate medical matters do to the inarticulate, the ugly and the mute? When lyrical verse vividly sums up the dimensions of a heartbeat and grand masters paint the doctor at work, what of the mundane and the aesthetically displeasing? What of the bodies with sagging bellies and trembling hands that cannot tell a compelling story? How can their bodily contours and greasy environs be included in an extended anatomy of humanity? The inadequacy and suffering of the woman with womb cancer and her family is neither noble nor picaresque. The glimpse of unhappy adults with slack bellies in a sordid home shows up the limits of wonder and the limits of the medical humanities to analyse suffering. A political and sociological analysis of inequality is necessary to get beyond description and avoid blaming victims for their own unhappiness.