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The Great Fall 2024 Book Preview
With the arrival of autumn comes a deluge of great books. Here you'll find a sampling of new and forthcoming titles that caught our eye here at The Millions, and that we think might catch yours, too. Some we’ve already perused in galley form; others we’re eager to devour based on their authors, plots, or subject matters. We hope your next fall read is among them.
—Sophia Stewart, editor
October
Season of the Swamp by Yuri Herrera, tr. Lisa Dillman [F]
What it is: An epic, speculative account of the 18 months that Benito Juárez spent in New Orleans in 1853-54, years before he became the first and only Indigenous president of Mexico.
Who it's for: Fans of speculative history; readers who appreciate the magic that swirls around any novel set in New Orleans. —Claire Kirch
The Black Utopians by Aaron Robertson [NF]
What it is: An exploration of Black Americans' pursuit and visions of utopia—both ideological and physical—that spans the Reconstruction era to the present day and combines history, memoir, and reportage.
Who it's for: Fans of Saidiya Hartman's Wayward Lives, Beautiful Experiments and Kristen R. Ghodsee's Everyday Utopia. —Sophia M. Stewart
The Third Realm by Karl Ove Knausgaard, tr. Martin Aitken [F]
What it is: The third installment in Knausgaard's Morning Star series, centered on the appearance of a mysterious new star in the skies above Norway.
Who it's for: Real Knausgaard heads only—The Wolves of Eternity and Morning Star are required reading for this one. —SMS
Brown Women Have Everything by Sayantani Dasgupta [NF]
What it is: Essays on the contradictions and complexities of life as an Indian woman in America, probing everything from hair to family to the joys of travel.
Who it's for: Readers of Durga Chew-Bose, Erika L. Sánchez, and Tajja Isen. —SMS
The Plot Against Native America by Bill Vaughn [F]
What it is: The first narrative history of Native American boarding schools— which aimed "civilize" Indigenous children by violently severing them from their culture— and their enduring, horrifying legacy.
Who it's for: Readers of Ned Blackhawk and Kathleen DuVal. —SMS
The Mighty Red by Louise Erdrich [F]
What it is: Erdrich's latest novel set in North Dakota's Red River Valley is a tale of the intertwined lives of ordinary people striving to survive and even thrive in their rural community, despite environmental upheavals, the 2008 financial crisis, and other obstacles.
Who it's for: Readers of cli-fi; fans of Linda LeGarde Grover and William Faulkner. —CK
The Position of Spoons by Deborah Levy [NF]
What it is: The second book from Levy in as many years, diverging from a recent streak of surrealist fiction with a collection of essays marked by exceptional observance and style.
Who it's for: Close lookers and the perennially curious. —John H. Maher
The Bog Wife by Kay Chronister [F]
What it's about: The Haddesley family has lived on the same West Virginia bog for centuries, making a supernatural bargain with the land—a generational blood sacrifice—in order to do so—until an uncovered secret changes everything.
Who it's for: Readers of Karen Russell and Jeff VanderMeer; anyone who has ever used the phrase "girl moss." —SMS
The Great When by Alan Moore [F]
What it's about: When an 18-year old book reseller comes across a copy of a book that shouldn’t exist, it threatens to upend not just an already post-war-torn London, but reality as we know it.
Who it's for: Anyone looking for a Sherlock Holmes-style mystery dipped in thaumaturgical psychedelia. —Daniella Fishman
The Message by Ta-Nehisi Coates [NF]
What it's about: One of our sharpest critical thinkers on social justice returns to nonfiction, nearly a decade after Between the World and Me, visiting Dakar, to contemplate enslavement and the Middle Passage; Columbia, S.C., as a backdrop for his thoughts on Jim Crow and book bans; and the Israeli-occupied West Bank, where he sees contemporary segregation in the treatment of Palestinians.
Who it’s for: Fans of James Baldwin, George Orwell, and Angela Y. Davis; readers of Nikole Hannah-Jones’s The 1619 Project and Isabel Wilkerson’s Caste, to name just a few engagements with national and racial identity. —Nathalie op de Beeck
Abortion by Jessica Valenti [NF]
What it is: Columnist and memoirist Valenti, who tracks pro-choice advocacy and attacks on the right to choose in her Substack, channels feminist rage into a guide for freedom of choice advocacy.
Who it’s for: Readers of Robin Marty’s The New Handbook for a Post-Roe America, #ShoutYourAbortion proponents, and followers of Jennifer Baumgartner’s [I Had an Abortion] project. —NodB
Gifted by Suzuki Suzumi, tr. Allison Markin Powell [F]
What it's about: A young sex worker in Tokyo's red-light district muses on her life and recounts her abusive mother's final days, in what is Suzuki's first novel to be translated into English.
Who it's for: Readers of Susan Boyt and Mieko Kanai; fans of moody, introspective fiction; anyone with a fraught relationship to their mother. —SMS
Childish Literature by Alejandro Zambra, tr. Megan McDowell [F]
What it is: A wide-ranging collection of stories, essays, and poems that explore childhood, fatherhood, and family.
Who it's for: Fans of dad lit (see: Lucas Mann's Attachments, Keith Gessen's Raising Raffi, Karl Ove Knausgaard's seasons quartet, et al). —SMS
Books Are Made Out of Books ed. Michael Lynn Crews [NF]
What it is: A mining of the archives of the late Cormac McCarthy with a focus on the famously tight-lipped author's literary influences.
Who it's for: Anyone whose commonplace book contains the words "arquebus," "cordillera," or "vinegaroon." —JHM
Slaveroad by John Edgar Wideman [F]
What it is: A blend of memoir, fiction, and history that charts the "slaveroad" that runs through American history, spanning the Atlantic slave trade to the criminal justice system, from the celebrated author of Brothers and Keepers.
Who it's for: Fans of Clint Smith and Ta-Nehisi Coates. —SMS
Linguaphile by Julie Sedivy [NF]
What it's about: Linguist Sedivy reflects on a life spent loving language—its beauty, its mystery, and the essential role it plays in human existence.
Who it's for: Amateur (or professional) linguists; fans of the podcast A Way with Words (me). —SMS
An Image of My Name Enters America by Lucy Ives [NF]
What it is: A collection of interrelated essays that connect moments from Ives's life to larger questions of history, identity, and national fantasy,
Who it's for: Fans of Ives, one of our weirdest and most wondrous living writers—duh; anyone with a passing interest in My Little Pony, Cold War–era musicals, or The Three Body Problem, all of which are mined here for great effect. —SMS
Women's Hotel by Daniel Lavery [F]
What it is: A novel set in 1960s New York City, about the adventures of the residents of a hotel providing housing for young women that is very much evocative of the real-life legendary Barbizon Hotel.
Who it's for: Readers of Mary McCarthy's The Group and Rona Jaffe's The Best of Everything. —CK
The World in Books by Kenneth C. Davis [NF]
What it is: A guide to 52 of the most influential works of nonfiction ever published, spanning works from Plato to Ida B. Wells, bell hooks to Barbara Ehrenreich, and Sun Tzu to Joan Didion.
Who it's for: Lovers of nonfiction looking to cover their canonical bases. —SMS
Blue Light Hours by Bruna Dantas Lobato [F]
What it's about: Through the emanating blue-glow of their computer screens, a mother and daughter, four-thousand miles apart, find solace and loneliness in their nightly Skype chats in this heartstring-pulling debut.
Who it's for: Someone who needs to be reminded to CALL YOUR MOTHER! —DF
Riding Like the Wind by Iris Jamahl Dunkle [NF]
What it is: The biography of Sanora Babb, a contemporary of John Steinbeck's whose field notes and interviews with Dust Bowl migrants Steinbeck relied upon to write The Grapes of Wrath.
Who it's for: Steinbeck fans and haters alike; readers of Kristin Hannah's The Four Winds and the New York Times Overlooked column; anyone interested in learning more about the Dust Bowl migrants who fled to California hoping for a better life. —CK
Innie Shadows by Olivia M. Coetzee [F]
What it is: a work of crime fiction set on the outskirts of Cape Town, where a community marred by violence seeks justice and connection; also the first novel to be translated from Kaaps, a dialect of Afrikaans that was until recently only a spoken language.
Who it's for: fans of sprawling, socioeconomically-attuned crime dramas a la The Wire. —SMS
Dorothy Parker in Hollywood by Gail Crowther [NF]
What it is: A history of the famous wit—and famous New Yorker—in her L.A. era, post–Algonquin Round Table and mid–Red Scare.
Who it's for: Owners of a stack of hopelessly dog-eared Joan Didion paperbacks. —JHM
The Myth of American Idealism by Noam Chomsky and Nathan J. Robinson [NF]
What it is: A potent critique of the ideology behind America's foreign interventions and its status as a global power, and an treatise on how the nation's hubristic pursuit of "spreading democracy" threatens not only the delicate balance of global peace, but the already-declining health of our planet.
Who it's for: Chomskyites; policy wonks and casual critics of American recklessness alike. —DF
Mysticism by Simon Critchley [NF]
What it is: A study of mysticism—defined as an experience, rather than religious practice—by the great British philosopher Critchley, who mines music, poetry, and literature along the way.
Who it's for: Readers of John Gray, Jorge Luis Borges, and Simone Weil. —SMS
Q&A by Adrian Tomine [NF]
What it is: The Japanese American creator of the Optic Nerve comic book series for D&Q, and of many a New Yorker cover, shares his personal history and his creative process in this illustrated unburdening.
Who it’s for: Readers of Tomine’s melancholic, sometimes cringey, and occasionally brutal collections of comics short stories including Summer Blonde, Shortcomings, and Killing and Dying. —NodB
Sonny Boy by Al Pacino [NF]
What it is: Al Pacino's memoir—end of description.
Who it's for: Cinephiles; anyone curious how he's gonna spin fumbling Diane Keaton. —SMS
Seeing Baya by Alice Kaplan [NF]
What it is: The first biography of the enigmatic and largely-forgotten Algerian artist Baya Mahieddine, who first enchanted midcentury Paris as a teenager.
Who it's for: Admirers of Leonora Carrington, Hilma af Klint, Frida Kahlo, and other belatedly-celebrated women painters. —SMS
Absolution by Jeff VanderMeer [F]
What it is: A surprise return to the Area X, the stretch of unforbidding and uncanny coastline in the hit Southern Reach trilogy.
Who it's for: Anyone who's heard this song and got the reference without Googling it. —JHM
The Four Horsemen by Nick Curtola [NF]
What it is: The much-anticipated cookbook from the team behind Brooklyn's hottest restaurant (which also happens to be co-owned by James Murphy of LCD Soundsystem).
Who it's for: Oenophiles; thirty-somethings who live in north Williamsburg (derogatory). —SMS
Seeing Further by Esther Kinsky, tr. Caroline Schmidt [F]
What it's about: An unnamed German woman embarks on the colossal task of reviving a cinema in a small Hungarian village.
Who it's for: Fans of Jenny Erpenbeck; anyone charmed by Cinema Paradiso (not derogatory!). —SMS
Ripcord by Nate Lippens [NF]
What it's about: A novel of class, sex, friendship, and queer intimacy, written in delicious prose and narrated by a gay man adrift in Milwaukee.
Who it's for: Fans of Brontez Purnell, Garth Greenwell, Alexander Chee, and Wayne Koestenbaum. —SMS
The Use of Photography by Annie Ernaux and Marc Marie, tr. Alison L. Strayer [NF]
What it's about: Ernaux's love affair with Marie, a journalist, while she was undergoing treatment for cancer, and their joint project to document their romance.
Who it's for: The Ernaux hive, obviously; readers of Sontag's On Photography and Janet Malcolm's Still Pictures. —SMS
Nora Ephron at the Movies by Ilana Kaplan [NF]
What it is: Kaplan revisits Nora Ephron's cinematic watersheds—Silkwood, Heartburn, When Harry Met Sally, You've Got Mail, and Sleepless in Seattle—in this illustrated book. Have these iconic stories, and Ephron’s humor, weathered more than 40 years?
Who it’s for: Film history buffs who don’t mind a heteronormative HEA; listeners of the Hot and Bothered podcast; your coastal grandma. —NodB
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The Philosophy of Translation by Damion Searls [NF]
What it is: A meditation on the act and art of translation by one of today's most acclaimed practitioners, best known for his translations of Fosse, Proust, et al.
Who it's for: Regular readers of Words Without Borders and Asymptote; professional and amateur literary translators alike. —SMS
Salvage by Dionne Brand
What it is: A penetrating reevaluation of the British literary canon and the tropes once shaped Brand's reading life and sense of self—and Brand’s first major work of nonfiction since her landmark A Map to the Door of No Return.
Who it's for: Readers of Christina Sharpe's Ordinary Notes and Elizabeth Hardwick's Seduction and Betrayal. —SMS
Masquerade by Mike Fu [F]
What it's about: Housesitting for an artist friend in present-day New York, Meadow Liu stumbles on a novel whose author shares his name—the first of many strange, haunting happenings that lead up to the mysterious disappearance of Meadow's friend.
Who it's for: fans of Ed Park and Alexander Chee. —SMS
November
The Beggar Student by Osamu Dazai, tr. Sam Bett [F]
What it is: A novella in the moody vein of Dazai’s acclaimed No Longer Human, following the 30-something “fictional” Dazai into another misadventure spawned from a hubristic spat with a high schooler.
Who it's for: Longtime readers of Dazai, or new fans who discovered the midcentury Japanese novelist via TikTok and the Bungo Stray Dogs anime. —DF
In Thrall by Jane DeLynn [F]
What it is: A landmark lesbian bildungsroman about 16-year-old Lynn's love affair with her English teacher, originally published in 1982.
Who it's for: Fans of Joanna Russ's On Strike Against God and Edmund White's A Boy's Own Story —SMS
Washita Love Child by Douglas Kent Miller [NF]
What it is: The story of Jesse Ed Davis, the Indigenous musician who became on of the most sought after guitarists of the late '60s and '70s, playing alongside B.B. King, Bob Dylan, John Lennon, and more.
Who it's for: readers of music history and/or Indigenous history; fans of Joy Harjo, who wrote the foreword. —SMS
Set My Heart on Fire by Izumi Suzuki, tr. Helen O'Horan [F]
What it is: Gritty, sexy, and wholly rock ’n’ roll, Suzuki’s first novel translated into English (following her story collection, Hit Parade of Tears) follows 20-year-old Izumi navigating life, love, and music in the underground scene in '70s Japan.
Who it's for: Fans of Meiko Kawakami, Ursula K. Le Guin, and Marlowe Granados's Happy Hour. —DF
Didion & Babitz by Lili Anolik [NF]
What it is: A dual portrait of Joan Didion and Eve Babitz, who are so often compared to—and pitted against—each other on the basis of their mutual Los Angeles milieu.
Who it's for: Fans or haters of either writer (the book is fairly pro-Babitz, often at Didion's expense); anyone who has the Lit Hub Didion tote bag. —SMS
The Endless Refrain by David Rowell [NF]
What it's about: How the rise of music streaming, demonitizing of artist revenue, and industry tendency toward nostalgia have laid waste to the musical landscape, and the future of music culture.
Who it's for: Fans of Kyle Chayka, Spence Kornhaber, and Lindsay Zoladz. —SMS
Every Arc Bends Its Radian by Sergio De La Pava [F]
What it is: A mind- and genre-bending detective story set in Cali, Colombia, that blends high-stakes suspense with rigorous philosophy.
Who it's for: Readers of Raymond Chandler, Thomas Pynchon, and Jules Verne. —SMS
Something Close to Nothing by Tom Pyun [F]
What it’s about: At the airport with his white husband Jared, awaiting a flight to Cambodia to meet the surrogate mother carrying their adoptive child-to-be, Korean American Wynn decides parenthood isn't for him, and bad behavior ensues.
Who it’s for: Pyun’s debut is calculated to cut through saccharine depictions of queer parenthood—could pair well with Torrey Peters’s Detransition, Baby. —NodB
Rosenfeld by Maya Kessler [F]
What it is: Kessler's debut—rated R for Rosenfeld—follows one Noa Simmons through the tumultuous and ultimately profound power play that is courting (and having a lot of sex with) the titular older man who soon becomes her boss.
Who it's for: Fans of Sex and the City, Raven Leilani’s Luster, and Coco Mellor’s Cleopatra and Frankenstein. —DF
Lazarus Man by Richard Price [F]
What it is: The former The Wire writer offers yet another astute chronicle of urban life, this time of an ever-changing Harlem.
Who it's for: Fans of Colson Whitehead's Crook Manifesto and Paul Murray's The Bee Sting—and, of course, The Wire. —SMS
Stranger Than Fiction by Edwin Frank [NF]
What it is: An astute curveball of a read on the development and many manifestations of the novel throughout the tumultuous 20th century.
Who it's for: Readers who look at a book's colophon before its title. —JHM
Letters to His Neighbor by Marcel Proust, tr. Lydia Davis
What it is: A collection of Proust’s tormented—and frequently hilarious—letters to his noisy neighbor which, in a diligent translation from Davis, stand the test of time.
Who it's for: Proust lovers; people who live below heavy-steppers. —DF
Context Collapse by Ryan Ruby [NF]
What it is: A self-proclaimed "poem containing a history of poetry," from ancient Greece to the Iowa Workshop, from your favorite literary critic's favorite literary critic.
Who it's for: Anyone who read and admired Ruby's titanic 2022 essay on The Waste Land; lovers of poetry looking for a challenge. —SMS
How Sondheim Can Change Your Life by Richard Schoch [NF]
What it's about: Drama professor Schoch's tribute to Stephen Sondheim and the life lessons to be gleaned from his music.
Who it's for: Sondheim heads, former theater kids, end of list. —SMS
The Serviceberry by Robin Wall Kimmerer [NF]
What it is: 2022 MacArthur fellow and botanist Kimmerer, an enrolled member of the Citizen Potawatomi Nation, (re)introduces audiences to a flowering, fruiting native plant beloved of foragers and gardeners.
Who it’s for: The restoration ecologist in your life, along with anyone who loved Braiding Sweetgrass and needs a nature-themed holiday gift. —NodB
My Heart Belongs in an Empty Big Mac Container Buried Beneath the Ocean Floor by Homeless [F]
What it is: A pseudonymous, tenderly comic novel of blue whales and Golden Arches, mental illness and recovery.
Who it's for: Anyone who finds Thomas Pynchon a bit too staid. —JHM
Yoke and Feather by Jessie van Eerden [NF]
What it's about: Van Eerden's braided essays explore the "everyday sacred" to tease out connections between ancient myth and contemporary life.
Who it's for: Readers of Courtney Zoffness's Spilt Milk and Jeanna Kadlec's Heretic. —SMS
Camp Jeff by Tova Reich [F]
What it's about: A "reeducation" center for sex pests in the Catskills, founded by one Jeffery Epstein (no, not that one), where the dual phenomena of #MeToo and therapyspeak collide.
Who it's for: Fans of Philip Roth and Nathan Englander; cancel culture skeptics. —SMS
Selected Amazon Reviews by Kevin Killian [NF]
What it is: A collection of 16 years of Killian’s funniest, wittiest, and most poetic Amazon reviews, the sheer number of which helped him earn the rarefied “Top 100” and “Hall of Fame” status on the site.
Who it's for: Fans of Wayne Koestenbaum and Dodie Bellamy, who wrote introduction and afterword, respectively; people who actually leave Amazon reviews. —DF
Cher by Cher [NF]
What it is: The first in a two-volume memoir, telling the story of Cher's early life and ascendent career as only she can tell it.
Who it's for: Anyone looking to fill the My Name Is Barbra–sized hole in their heart, or looking for something to tide them over until the Liza memoir drops. —SMS
The City and Its Uncertain Walls by Haruki Murakami, tr. Philip Gabriel [F]
What it is: Murakami’s first novel in over six years returns to the high-walled city from his 1985 story "Hard-Boiled Wonderland and the End of the World" with one man's search for his lost love—and, simultaneously, an ode to libraries and literature itself.
Who it's for: Murakami fans who have long awaited his return to fiction. —DF
American Bulk by Emily Mester [NF]
What it's about: Reflecting on what it means to "live life to the fullest," Mester explores the cultural and personal impacts of America’s culture of overconsumption, from Costco hauls to hoarding to diet culture—oh my!
Who it's for: Lovers of sustainability; haters of excess; skeptics of the title essay of Becca Rothfeld's All Things Are Too Small. —DF
The Icon and the Idealist by Stephanie Gorton [NF]
What it is: A compelling look at the rivalry between Margaret Sanger, of Planned Parenthood fame, and Mary Ware Dennett, who each held radically different visions for the future of birth control.
Who it's for: Readers of Amy Sohn's The Man Who Hated Women and Katherine Turk's The Women of NOW; anyone interested in the history of reproductive rights. —SMS
December
Rental House by Weike Wang [F]
What it's about: Married college sweethearts invite their drastically different families on a Cape Code vacation, raising questions about marriage, intimacy, and kinship.
Who it's for: Fans of Wang's trademark wit and sly humor (see: Joan Is Okay and Chemistry); anyone with an in-law problem.
Woo Woo by Ella Baxter [F]
What it's about: A neurotic conceptual artist loses her shit in the months leading up to an exhibition that she hopes will be her big breakout, poking fun at the tropes of the "art monster" and the "woman of the verge" in one fell, stylish swoop.
Who it's for: Readers of Sheena Patel's I'm a Fan and Chris Kraus's I Love Dick; any woman who is grateful to but now also sort of begrudges Jenny Offil for introducing "art monster" into the lexicon (me). —SMS
Berlin Atomized by Julia Kornberg, tr. Jack Rockwell and Julia Kornberg [F]
What it's about: Spanning 2001 to 2034, three Jewish and downwardly mobile siblings come of age in various corners of the world against the backdrop of global crisis.
Who it's for: Fans of Catherine Lacey's Biography of X and Joshua Cohen's The Netanyahus. —SMS
Sand-Catcher by Omar Khalifah, tr. Barbara Romaine [F]
What it is: A suspenseful, dark satire of memory and nation, in which four young Palestinian journalists at a Jordanian newspaper are assigned to interview an elderly witness to the Nakba, the violent 1948 expulsion of native Palestinians from Israel—but to their surprise, the survivor doesn’t want to rehash his trauma for the media.
Who it’s for: Anyone looking insight—tinged with grim humor—into the years leading up to the present political crisis in the Middle East and the decades-long goal of Palestinian autonomy. —NodB
The Shutouts by Gabrielle Korn [F]
What it's about: In the dystopian future, mysteriously connected women fight to survive on the margins of society amid worsening climate collapse.
Who it's for: Fans of Korn's Yours for the Taking, which takes place in the same universe; readers of Becky Chambers and queer-inflected sci-fi. —SMS
What in Me Is Dark by Orlando Reade [NF]
What it's about: The enduring, evolving influence of Milton's Paradise Lost on political history—and particularly on the work of 12 revolutionary readers, including Malcom X and Hannah Arendt.
Who it's for: English majors and fans of Ryan Ruby and Sarah Bakewell—but I repeat myself. —SMS
The Afterlife Is Letting Go by Brandon Shimoda [NF]
What it's about: Shimoda researches the mass incarceration of Japanese Americans during WWII, and speaks with descendants of those imprisoned, for this essay collection about the “afterlife” of cruelty and xenophobia in the U.S.
Who it’s for: Anyone to ever visit a monument, museum, or designated site of hallowed ground where traumatic events have taken place. —NodB
No Place to Bury the Dead by Karina Sainz Borgo, tr. Elizabeth Bryer [F]
What it's about: When Angustias Romero loses both her children while fleeing a mysterious disease in her unnamed Latin American country, she finds herself in a surreal, purgatorial borderland where she's soon caught in a power struggle.
Who it's for: Fans of Maríana Enriquez and Mohsin Hamid. —SMS
The Rest Is Silence by Augusto Monterroso, tr. Aaron Kerner [F]
What it is: The author of some of the shortest, and tightest, stories in Latin American literature goes long with a metafictional skewering of literary criticism in his only novel.
Who it's for: Anyone who prefers the term "palm-of-the-hand stories" to "flash fiction." —JHM
Tali Girls by Siamak Herawi, tr. Sara Khalili [F]
What it is: An intimate, harrowing, and vital look at the lives of girls and women in an Afghan mountain village under Taliban rule, based on true stories.
Who it's for: Readers of Nadia Hashimi, Akwaeke Emezi, and Maria Stepanova. —SMS
Sun City by Tove Jansson, tr. Thomas Teal [F]
What it's about: During her travels through the U.S. in the 1970s, Jansson became interested in the retirement home as a peculiarly American institution—here, she imagines the tightly knit community within one of them.
Who it's for: Fans of Jansson's other fiction for adults, much of which explores the lives of elderly folks; anyone who watched that documentary about The Villages in Florida. —SMS
Editor's note: We're always looking to make our seasonal book previews more useful to the readers, writers, and critics they're meant to serve. Got an idea for how we can improve our coverage? Tell me about it at sophia@themillions.com.
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Bitter Pill: The Modern Medicine Lament
"My Best Friend, my doctor, won't even say what it is I've got."-Bob DylanI recently became aware of a trend, the Modern Medicine Lament, in which American writers struggle to make an uneasy peace with a system from which they feel alienated. And it begs the question: has it always been this way?Doctors have enjoyed a colorful depiction in books and letters over the years. Kafka's brilliant short story "A Country Doctor" is still read and taught frequently. Boris Pasternak's Dr. Zhivago was a man of principle in any language, in any time. Chekhov was a trained physician. I should also mention my favorite doctor in literature, Dr. Livesey, from Robert Louis Stevenson's Treasure Island. Stevenson, you'll recall, sketched another doctor, Dr. Jekyll, whose enthusiasm for chemicals took him off the rails (if Jekyll lived in America today he would surely declaim in a basement recovery meeting about the social transgressions committed by his intoxicated self). Mary Shelley's Frankenstein, written almost 200 years ago, offers a remarkable foreshadowing of the moral and ethical challenges inherent to the practice of medicine, which has always had one ultimate goal: triumph over death. It is telling that we will in passing mistake the name of the title character for that of the monster.In 1885 Louis Pasteur, a Frenchman, first administered vaccine to a human, a child bitten by a rabid dog. The treatment was successful. It was not an insignificant moment in human history. Giant scientific leaps forward like Pasteur's continue to inject health and medicine into the lives of everyday people. Vaccines and antibiotics changed the world, though today their administration is practically mundane. In America, where good health has always been considered something of a birthright, we resent doctors. They are a necessary evil, a reminder of the basic infirmity of our bodies and the inevitability of their decline. Sure, Americans love watching fictional doctors treat fictional patients on television, but in reality aren't doctors society's consummate whipping boys? After all, that goal - sticking it to death - has never yet been achieved. Good news from a doctor cannot amount to more than "you will live for maybe a few more years, all things being equal." And anyway, Americans don't want to live forever, they simply want their life on earth to be pain-free, and believe it should be.Pills that govern the chemical workings of the brain are now at the forefront of our ever-advancing medical knowledge. They treat disorders like depression, schizophrenia, autism, addiction, panic, mania, and garden-variety anxiety. Neurochemistry remains the least understood field in medicine, but the sales figures of these drugs have exploded in the past twenty years. Pharmaceutical manufacturers employ direct advertising - and also work more quietly through doctors - to encourage the public to treat a psychological condition far enough from bliss as a disorder. Comparatively little attention is paid to the fresh array of stresses and overload of stimuli that burden the modern brain, and how these factors can capitalize on the ease of modern life, where we are at greater leisure to explore exactly how we feel, as opposed to wasting all of our energy on mere survival. Effexor, Wellbutrin, Paxil, Zoloft, Prozac: ugly mash-ups, yes, but also household words. The drugs have brought relief to millions of people suffering from mental duress.But the rise of Psychotropic Nation has created a cultural preoccupation with pills here in the U.S., one that has in turn given rise to questions about the efficacy of our medical system (actually just one of many aspects of our system that provoke such questions). If you are writing a novel, say, and wish to introduce recreational drug use into the plot (you may want the characters to seem more subversive, irrational, hedonistic, or edgy), you might shy away from the ho-hum world of schedule 1 drugs: your pot, your cocaine and heroin - in favor of those that can be obtained with a doctor's note: pain pills, sedatives, amphetamines. The irony payoff is just too great, and writers love irony. The companies that make these drugs want you to want them, but as soon as you do, you probably should not have them. And maybe you, the writer (or the characters for that matter), don't have health insurance, or went through a period when you weren't covered - that just adds to the irony. Without insurance you're not seeing a doctor, making it a whole lot easier for you to go schedule 1 than to buy a bottle of valium. And, given the cost of such pills, cheaper too.Jonathan Franzen wrote extensively on this aspect of American life (see also Ben Kunkel's Indecision, in which psychopharmacology plays no small roll). In The Corrections the drug is called Aslan, and its effects are somewhere between Prozac and ecstasy. At least two Lamberts use the drug, Chip during an unfortunate weekend sex binge, and Enid, Chip's mother, whose little helper gets her rather strung out over a longer period. Franzen's treatment is made more complete as Gary, eldest of the Lambert kids (and hilariously aware of the ebb and flow of his own serotonin and dopamine levels) invests money in the drug company that makes Aslan. Meanwhile, the pill is pushed by a leonine doctor with a creepy, guru-like aspect. And, of course, the one individual who could really use a pick-me-up, the crushingly depressed father Alfred, gets none. Collective dysphoria has never been so amusing.Life imitates art, but it's no barrel of laughs. That said, the cover story of this month's Harper's, "Manufacturing Depression: A Journey into the Economy of Melancholy", by Gary Greenberg, does deliver the odd ironic chortle. Mr. Greenberg, a psychotherapist, is writing a book about the "misuses of medical diagnoses," and if his magazine piece is any indication, it may be worth reading. The piece opens with Mr. Greenberg cataloging the failures and dissatisfactions of his life to a kindly psychiatrist, Dr. George Papakostas, in order to see if he qualifies for an experimental drug study at the Depression Clinical and Research Program of Massachusetts General Hospital. And, after checking some boxes, the doctor delivers his diagnosis: Mr. Greenberg has Major Depression. Would he like to try Celexa, Lexapro, Mirapex, or omega-3 fish oil?"It was hard to believe that Papakostas really thought I had major depression," writes Mr. Greenberg. Mr. Greenberg does feel bad sometimes, inadequate, feckless, and yes, his hair is thinning. His life is not blissful. But what is made abundantly clear to him is that the clinical criteria for a diagnosis of Depression, codified in the psychiatrist-developed Structured Clinical Interview, are bunk. Your score on this questionnaire, determined by the doctor, is totally subjective, the questions laughably interpretive. Dr. Papakostas, looking for subjects for a drug study driven by new medicines from Forest Laboratories, Inc. and paid for by the federal government, is predisposed towards a diagnosis of Clinical Depression. That's really what someone looking to join such a study wants to hear, right? "'Are you content with the amount of happiness that you get doing things that you like..?'" It is a standardized question asked by the doctor at one of Mr. Greenberg's weekly follow-ups. "'I'm not big on contentment,' I said. Is anyone? I wondered. Is anyone ever convinced that his or her pursuit of happiness has reached its goal? And what would happen to the consumer economy if we began to believe that any amount of happiness is enough?"The uncomfortable intersection of the consumer economy and medicine is at the heart of an article by Bruce Stutz that appeared in the May 6 issue of the NY Times Magazine. Unlike Mr. Greenberg, who never believes that he is clinically depressed even as he dutifully takes his Mass General fish oil, Mr. Stutz begins from a different point of view: he, like millions of Americans, went through a period of debilitating depression for which he sought medical treatment. Talk therapy and a prescribed selective serotonin reuptake inhibitor, Effexor, worked for him. Three years and a more positive outlook on life later, Mr. Stutz found himself shaking hands with his psychiatrist at the conclusion of his final session. But there was no mention of going off the drug."Somehow I couldn't believe I had to take this pill for the rest of my life," he writes. How many people taking such medication have had that thought? It's not just the side effects, the occasional bouts of impotence, the weight gain, the dulled sensory perceptions and emotions, and it's not just the monetary cost of the pills. It is also living with a stigmatizing reminder that one is sick and will never be well. But Mr. Stutz was well: he felt better; he was able to go one with his life. The stresses that had predicated his mental slide, the death of a parent, the breakup of a marriage, the loss of a job, were in the rearview. So he tapered his meds and hunkered down. Fierce withdrawal symptoms followed: mental torpor, physical discomfort, and the frightening "brain zaps," blinding, incapacitating insta-headaches. With the help of some experts in clinical biology, Mr. Stutz does an admirable job of elucidating the chemical processes that were at work in his brain, which was, without the help of the meds, running a serotonin deficit. What Mr. Stutz did not experience during that period was a return of his depression symptoms. And so he wonders, "does our long-term reliance on these drugs become more of a convenience than a cure?"Drug companies and doctors have about as much interest in helping people go off their psych meds as tobacco execs have in helping people quit cigarettes. Still, the medical industry is simply giving us what we want, a quick fix. What happens when the quick fix goes bad? The title of Ann Bauer's May 18 article on Salon.com, "Psych Meds Drove My Son Crazy", is inelegant but to the point. Her story is gripping, horrifying, and ultimately infuriating. Mrs. Bauer's eldest son was born with autism. At the age of 17 this highly functional kid living in Minnesota became depressed, and his mother took him to a psychiatrist who prescribed an anti-depressant, which, she was assured, would not only snap him out of his funk, but also help control some of his autism-related obsessive tendencies. Instead, his condition grew worse. Doctors at a "respected neuropsychology clinic" reevaluated Mrs. Bauer's son, now 30 pounds heavier and sleeping 16 hours a day, and changed the original diagnosis: in addition to his autism, her son was experiencing "'psychomotor slowing' - a form of schizophrenia." And so a different drug was prescribed, Abilify, which was new (and, Mrs. Bauer notes, had been marketed direct-to-consumer in Time and Newsweek). Still her son's condition worsened, "humming, shifting foot to foot, screaming if anyone touched him or tried to move him." He would dialogue with voices that Mrs. Bauer could not hear. She tapered him off the Abilify.Two days later he "got out of bed and stood in one place for a solid hour." When Mrs. Bauer placed a hand on him, he beat her up.Amazingly, the doctors managed to convince Mrs. Bauer to try yet another drug, a powerful anti-psychotic, Geodon. Her son took to living on the street after that. Only by conducting her own research, and getting a lucky referral to the Mayo Clinic from a retired doctor in Stony Brook, N.Y., an expert in a little known condition called autistic catatonia, did Mrs. Bauer find her son proper medical care. It took two years. Five days after checking him into Mayo, Mrs. Bauer read a front-page story in the NY Times "about psychiatrists in Minnesota who were collecting money from drug manufacturers for prescribing atypical antipsychotics, including Abilify and Geodon." The article cited some hefty payout numbers, and also some serious risk factors for the drugs. It did not mention a fact that the doctors at Mayo confirmed: administered to an individual suffering from autistic catatonia, which they determined was the root cause of her son's initial decline, neuroleptics like Abilify and Geodon only amplify the effects of the disorder, and they can cause permanent neurological damage.She doesn't say so, but I really hope Mrs. Bauer sued the pants off some folks. I would be interested to know.There will be more Modern Medicine Laments to come. We will read them, and we will also watch with interest TV shows like "The Sopranos", in which the writers have taken an increasingly critical line on the treatment of depression in America, and films like Michael Moore's upcoming documentary about the ills of the American health care system. We will see more legal settlements against drug manufacturers like Purdue Pharma (OxyContin) and Pfizer (Celebrex) for misrepresenting the effects of their products to the consumer public. And, of course, we will continue to pop pills. We are a nation of armchair doctors. Sometimes it seems like a prescription pad is the only thing separating us from the real thing.Update: The Libra in me desires balance. I do not want this post to seem an ad hoc dismissal of the medical profession as a whole. So I would steer folks to a book, Mountains Beyond Mountains, by Tracy Kidder, that had a profound impact on me when I read it. The book is about Dr. Paul Farmer, whose work battling T.B. while bringing basic medical care to corners of the world like Haiti and Peru where none existed before makes him something of a medical superhero. Kidder's profile of Dr. Farmer proves that modern medicine is still changing the world for the better.