Indecision: A Novel

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The Truce Between Fabulism and Realism: On Gabriel Garcia Marquez and the Modern Novel

1. When Gabriel Garcia Marquez died in April, the general flow of eulogy settled on two interpretations of his legacy: in the first, as a titanic but essentially regional author (The Times obituary called One Hundred Years of Solitude “the defining saga of Latin America’s social and political history”); in the second, as a model for the diminishing novelties of subsequent magical realists, like Salman Rushdie and Isabel Allende. Fair enough. Garcia Marquez himself saw his style as fundamentally linked to the politics of his continent in his lifetime. (Correctly -- for example, nothing has ever better captured how important the theft of time must feel in a totalitarian state than the dictator who lives on and on for centuries in The Autumn of the Patriarch.) It’s also true that he gave license to a new kind of fabulism, unique in that it didn’t descend from Swift or Cervantes, and therefore didn’t depend on either satire or comedy to atone for the recklessness of its inventions. Those are narrow channels of influence, however, and there’s a third, untracked, more expansive reading of his work to make. It might go like this: he solved an essential problem of the novel; he arrived at a moment of crisis for the form and offered the warring parties a graceful way out of it; and if there’s a single novel that can claim paternity for the last 20 years of American fiction, it’s probably One Hundred Years of Solitude. 2. That book was published in America in 1972, and it was a sensation, critically and commercially, William Kennedy famously calling it, with un-Albanyish zeal, “the first piece of literature since the Book of Genesis that should be required reading for the entire human race.” (If you somehow haven’t heard of it, One Hundred Years of Solitude is the multi-generational chronicle of a Colombian family called the Buendias.) At the time, there was a battle afoot between two kinds of fiction. Writers like Jean Stafford and Michael Shaara, traditional realists, were winning the Pulitzer Prize, while the National Book Award, inclined toward a more radical approach, went to John Barth and William Gaddis, campus experimentalists grinding out the logical final steps of the project inaugurated by Borges, by Ulysses, Hopscotch, Albert Angelo. Each side loathed the other. Updike’s declaration about Thomas Pynchon -- “I don’t like the funny names” -- might as well stand in for the whole cultural apparatus that was committed to realism; on the other hand Barth’s foundational postmodernist essay “The Literature of Exhaustion” called realism “used up,” and Gaddis said that such writing “never takes your breath away...it’s for people who read with the surface of their minds, people with reading habits that make the smallest demands on them.” The great formal achievement of One Hundred Years of Solitude was that it treated the two positions not as antipodal but as dialectical. It satisfied the modernist commitment to narrative innovation in two ways, first in its compression and dilation of time -- what would become the hallmark of magical realism -- and second in its use of the fantastic, the twins who die at the same instant, the visitation of the ghosts, the glass city, Remedios being sublimated into heaven as she does the laundry. But Garcia Marquez made the ingenious decision to embed those moments of originality within the stubbornly enduring structure of the traditional realist novel, turning his book into a family saga by way of a dream -- Trollope by way of Barthelme. By doing so, he managed to defuse a central tension, one that had divided novelists since Hemingway and Joyce pitched their opposing camps. Of course, there were writers before Garcia Marquez who had blended the magical and the prosaic (Kafka, most famously) but none of them were perhaps as fully committed to narrative as Garcia Marquez seemed -- to story. Meanwhile, other writers across the world had the same impulse, many of them, interestingly, in totalitarian states, including Milan Kundera and Danilo Kis, but their books were being passed around in samizdat, not, as Garcia Marquez’s was, in suburban book clubs and city libraries. What makes One Hundred Years of Solitude a watershed moment of cultural history is that mix of plot, experimentation, acclaim, and popularity. That’s also why its influence has been so subtly pervasive. Many of our heaviest hitters -- Franzen, Wallace, Eisenberg, Tartt, Saunders, Chabon -- were born around 1960, and therefore came of age during the book’s ascendancy. Considered in that light, their debt to it seems plain, whether or not they would acknowledge it, whether or not they found the book stimulating, indeed whether or not they’ve even read it. The reason is that all of them play the same trick, filigreeing traditional realism with enough carefully selective post-modernism to claim its gloss of coolness -- but without the unfortunate consequence of making their work difficult to read. In The Adventures of Kavalier and Clay there’s the Golem of Prague; in The Art of Fielding there’s the self-consciously literary exhumation of the corpse; in The Corrections, there’s the magical device of Correctall, the pill that allows Chip Lambert to forget his anxiety and enter a state of dreamlike euphoria. (It’s a sign of our age how often American magical realism is pharmaceutical, after Franzen’s example -- the decision-making drug in Indecision by Benjamin Kunkel; the test subjects in George Saunders’s magnificent “Escape from Spiderhead.”) Fiction is an essentially conventional art form, most at home in the bourgeoisie, but its practitioners have -- quite rightly! -- never been at ease with that fact. The compromise at which we’ve arrived is that every book now has the credibility of the avant-garde within a Victorian structure. It’s more fun to claim the influence of John Hawkes than John Galsworthy; it’s more fun to read a book whose plot is patterned after Jane Austen than B.S. Johnson. 3. Unsurprisingly, the first American novelist to take the full implications of Garcia Marquez on board may have been our smartest one, Philip Roth. (It’s not a coincidence that he spent the 1970s publishing Eastern European novelists, and, as Roth Unbound described, sneaking money to them via illicit networks -- a fact that ought to shame the Nobel committee members who have claimed that American writers are unworthy of the prize because they’re too inward-looking, too insular.) His books The Counterlife and Operation Shylock were precursors of the great florescence of faux-mo novels in the 2000’s, using false flags and mirrored characters without their pace or urgency. The logical culmination of the trend is probably The Marriage Plot, which states the tension outright, dropping a college student who just wants to read 19th-century novels into the semiotics craze of the 1980s. At their weakest, these post-Garcia Marquez books have been kinetic without moving, emotional without evoking any real sensation, readable without deserving to be read. The novel of this type that comes to mind for me is Absurdistan by the sometimes terrific Gary Shteyngart, a disagreeable blend of absurdism and soft sentimentality. Michael Chabon, Jonathan Lethem, Junot Diaz, Jonathan Safran Foer, and Colson Whitehead can feel similarly limited by their very limitlessness -- their work at times too ironized for readers to treat its narrative seriously, but too committed to narrative to offer the sense of alienation, dread, and obliqueness we feel in, for example, Don DeLillo and William Gibson. The writer for whom cultural critics were so eager to give Garcia Marquez credit, Salman Rushdie, might be the least exciting of the bunch. The Pale King offers a glimpse of what David Foster Wallace’s pushback against his own trend might have looked like -- his reconnection with difficulty as a means of higher artistic consciousness. Recent Pulitzer Prize committees have waded into this fray again; books of high seriousness, eschewing the jokey gloss of the comic book generation, have won the prize, including three lovely but deeply conservative novels, Tinkers by Paul Harding, March by Geraldine Brooks, and Olive Kitteredge by Elizabeth Strout. How much does that matter? The painter Gerhard Richter has spent the last 50 years dissolving what previously seemed like a crucial distinction between figurative and abstract painting; is it possible that novelists, too, no longer need to declare a single allegiance? If so, the books that Garcia Marquez gave a generation permission to write, produced during the truce between fabulism and realism, may begin to look odd: artifacts of the historical moment they thought they were creating. One of the pieces of shallow wisdom people like to repeat is that every great book either creates or dissolves a genre, and sometimes it’s true. One Hundred Years of Solitude, though it hasn’t quite received credit for this, established the school of fiction we currently consider great. It’s up to some other genius to dissolve it.

20 More Under 40

One might have imagined that the emergence of an online kommentariat would have made The New Yorker's 2010 "20 Under 40" Fiction Issue, released last week, an even bigger buzz engine than its 1999 predecessor. For some reason, though - high humidity in the mid-Atlantic? the preponderance of Knopf and FSG authors? the preexistence of a Granta theme issue with significant overlap? the nebulous formulation "writers who we believe are, or will be, key to their generation"? - the magazine's list of the best young American fiction writers has met mostly with polite golf clapping. To be sure, it's hard to begrudge these 20 terrific writers their honor. We've been excited to read in the issue new work from friends (and interested to observe the generational influence exerted by 1999 honoree George Saunders). But, as the accompanying Comment suggests, "to encourage . . . second-guessing is perhaps the best reason to make lists." And, wishing to see more such second-guessing, we've decided to rise to the bait and offer our own, non-overlapping, list of young-ish writers to watch. The exercise gave us a new appreciation for The New Yorker's editorial staff: It turns out to be damn hard to figure out who to call American. (There's also a shocking number of writers who are 40 this year: Brady Udall, Nathan Englander, Ed Park, Danzy Senna, Paul LaFarge...). It's nice to be reminded, however, as we all wring our hands about the future of fiction, of the preponderance of of thirtysomething talent out there. So, with apologies for obviousness, we hereby present an informal, unscientific, alternate-universe "20 Under 40" list. Calvin Baker's three works of fiction range fearlessly across the expanse of American experience from the Middle Passage forward. In Dominion, one of several recent novels to tackle the antebellum period, Baker finds his own, hybrid solution to the challenge of voicing the past. Jesse Ball's first two novels, Samedi the Deafness and The Way Through Doors, both reviewed here, show off a fabulist sensibility that's somehow both minimalist and maximalist - Paul Auster by way of The Arabian Nights. Ball won The Paris Review's Plimpton Prize for fiction in 2008. Chris Bachelder, author of Bear vs. Shark and U.S.! wields the two weapons all great satirists need: an eye for the absurd and a deep moral sense. For what it's worth, Bachelder's remarkable lexicon had at least one reader convinced for a few weeks in 2007 that he was a pseudonym of David Foster Wallace. Mischa Berlinski's first novel, Fieldwork, like the best fieldwork, moves beyond the parochial concerns of the American writing program without resorting to exoticism. It was a National Book Award finalist. Berlinski is currently in Haiti, we're told, working on another. Tom Bissell, who has lately published nonfiction in The New Yorker, might have been a plausible candidate for inclusion on its list. His first collection of short fiction, God Lives in St. Petersburg, was a finalist for the Believer Book Award. Judy Budnitz is one of America's great unsung short-story writers. Her two collections, Flying Leap and Nice Big American Baby marry Kafka-esque premises with a ruthless willingness to follow them to their conclusions. Also a novelist, she made the Granta list a couple years back. Joshua Cohen, a prolific (and quotably bellicose) 29-year-old, just published his sixth book, a Ulyssean 800-pager called Witz. Expect serious reviews to start appearing in the fall, when people have actually finished the damned thing. Kiran Desai is now a permanent resident of the U.S....or so says Wikipedia. Her 2006 novel, The Inheritance of Loss, was a Booker Prize winner and was on a lot of people's year-end lists. Myla Goldberg may have lost some credibility with literary mandarins when her first novel, Bee Season, became a Richard Gere vehicle. However, her second novel, Wickett's Remedy, shows that her ambitions extend well beyond orthography. Sheila Heti, a puckish Canadian, can be on our list if David Bezmozgis can be on The New Yorker's. Her first collection, The Middle Stories, featured fables skewed sui generisly. She's since published a novel, Ticknor, and appeared as Lenore in Leanne Shapton's Important Artifacts. Samantha Hunt's most recent novel, The Invention of Everything Else, was a fabulist meditation on Nikola Tesla; her previous piece, The Seas, was similarly inventive. Like Heti and Bissell, she cut her teeth in McSweeney's. Porochista Khakpour's debut, Sons and Other Flammable Objects, showed off her acrobatic voice; recent work in Guernica suggests more of the same. Benjamin Kunkel, aside from having mastered the voice of bemused neuroticism in Indecision, has one of the most interesting minds around, as evidenced by his far-ranging criticism in The London Review of Books. A play, Buzz, is forthcoming from N+1. Victor LaValle's third book, the splendidly eccentric Big Machine, has been his breakout. A Publisher's Weekly best novel of 2009, it has won him many fans, including our own Edan Lepucki, who reviewed it here last fall. Fiona Maazel's Last Last Chance is one of the most ambitious debuts of recent years, covering plague, addiction, and chicken processing. Maazel was a Lannan Foundation fellow in 2005. Joe Meno, unlike any writer on the New Yorker list, published his first few novels with an independent press, Brooklyn's Akashic Books. A writer of considerable range, the Chicago-based Meno last year published a rollicking family novel, The Great Perhaps, which occasioned an interview with and profile by Edan. Julie Orringer spent the several years of radio silence that followed her feted story collection, How to Breathe Underwater, productively. Her expansive first novel, The Invisible Bridge, has been hailed for its historical sweep and intimate portraiture. Salvador Plascencia's memorably and typographically strange novel, The People of Paper, rivals Chris Adrian's The Children's Hospital for the title of Most Interesting Novel McSweeney's Has Published (Non-Eggers Division). We have no idea what he's working on now, but we look forward to it. Eric Puchner is the author of Music Through the Floor, a collection that won the NYPL's Young Lions Award. This year, he published the similarly well-received novel Model Home. His wry essay about being married to the novelist Katharine Noel can be found here. Anya Ulinich's debut, Petropolis, rendered the life of a post-Soviet expatriate with Bellovian figurative brio. She's got a great story called "Mr. Spinach" floating around out there somewhere...hopefully part of a collection?

The Best Fiction of the Millennium (So Far): An Introduction

Ah, 1999... We laughed along with Chandler and Phoebe, invested our surplus Benjamins with Lehman Brothers, danced a national macarena. Those days seem like the distant past now, and in many ways, the first decade of the 21st Century has been quite different from the giddy future we might have projected. In one way, though, the new millennium has delivered: we've gotten great fiction, often from unexpected quarters. When The New York Times named "The Best Work of American Fiction of the Last 25 Years" in 2006, none of the finalists was younger than 69, and the most recent publication date was 1997. But the '00s have introduced us to new voices, spurred others to new levels of achievement, and ushered in the late masterworks that have capped distinguished careers. It's a bit early, of course, to pass definitive judgment on the literary legacy of the '00s, or how it stacks up against that of the 1930s, or 1850s. Who knows what will be read 50 years from now? But, with the end of the decade just a few months away, it seemed to us at The Millions a good time to pause and take stock, to call your attention to books worthy of it, and perhaps to begin a conversation. To that end, we've conducted a poll of our regular contributors and 48 of our favorite writers, editors, and critics (listed below), asking a single question: "What are the best books of fiction of the millennium, so far?" The results were robust, diverse, and surprising. We've finished tabulating them, and this week, we'll be counting down the Top 20 vote-getters, at a rate of five per day. Each book will be introduced by one of the panelists who voted for it. On Friday, we'll reveal Number One, along with the results of a parallel reader poll conducted via our Facebook group. And next week, we'll run follow-up posts including Honorable Mention and "Best of the Rest" lists. This page, updated as we post the list, will become an index. You can use it to navigate the series, or can check back at our home page; we also invite you to consider subscribing to The Millions via RSS feed or Kindle.  We hope you'll share your thoughts here or on the entries for the individual books throughout the week as our list is revealed. The List #20: Gilead by Marilynne Robinson #19: American Genius, A Comedy by Lynne Tillman #18: Stranger Things Happen by Kelly Link #17: The Fortress of Solitude by Jonathan Lethem #16: Middlesex by Jeffrey Eugenides #15: Varieties of Disturbance by Lydia Davis #14: Atonement by Ian McEwan #13: Mortals by Norman Rush #12: Twilight of the Superheroes by Deborah Eisenberg #11: The Brief, Wondrous Life of Oscar Wao by Junot Díaz #10: Never Let Me Go by Kazuo Ishiguro #9: Hateship, Friendship, Courtship, Loveship, Marriage by Alice Munro #8: Out Stealing Horses by Per Petterson #7: Austerlitz by W.G. Sebald #6: The Road by Cormac McCarthy #5: Pastoralia by George Saunders #4: 2666 by Roberto Bolaño #3: Cloud Atlas by David Mitchell #2: The Known World by Edward P. Jones #1: The Corrections by Jonathan Franzen The Panel Sam Anderson is the book critic for New York Magazine. Rosecrans Baldwin is the author of the forthcoming You Lost Me There and a founding editor of The Morning News. Elif Batuman is the author of the forthcoming The Possessed: Adventures With Russian Books and the People Who Read Them Mark Binelli is the author of Sacco and Vanzetti Must Die and is a contributor to Rolling Stone. Elise Blackwell is the author of Hunger and other books Patrick Brown is a contributor to The Millions. Sonya Chung is the author of Long for This World and is a contributor to The Millions. Elizabeth Crane is the author of You Must Be This Happy to Enter and other works of fiction. Ben Dolnick is the author of Zoology. Ben Ehrenreich is the author of The Suitors. Stephen Elliot is the author of The Adderall Diaries and other books and is founding editor of The Rumpus. Scott Esposito is the founding editor of Conversational Reading and The Quarterly Conversation. Joshua Ferris is the author of Then We Came to the End and the forthcoming The Unnamed. Rivka Galchen is the author of Atmospheric Disturbances. Lauren Groff is the author of Delicate Edible Birds and The Monsters of Templeton. Garth Risk Hallberg is the author of A Field Guide to the North American Family and is a contributor to The Millions. John Haskell is the author of Out of My Skin and American Purgatorio. Jeff Hobbs is the author of The Tourists. Michelle Huneven is the author of Blame and other novels. Samantha Hunt is the author of The Invention of Everything Else and The Seas. Sara Ivry is a senior editor of Tablet. Bret Anthony Johston is the author of Corpus Christi: Stories and is director of the Creative Writing Program at Harvard University. Porochista Khakpour is the author of Sons and Other Flammable Objects. Lydia Kiesling is a contributor to The Millions. Benjamin Kunkel is the author of Indecision and is a founding editor of N+1. Paul La Farge is the author of Haussmann, or The Distinction. Reif Larsen is the author of The Selected Works of T.S. Spivet. Dorothea Lasky is the author of Awe and other books. Edan Lepucki is a contributor to The Millions. Yiyun Li is the author of The Vagrants Margot Livesey is the author of The House on Fortune Street and other books. Fiona Maazel is the author of Last Last Chance. C. Max Magee is the founding editor of The Millions. Sarah Manguso is the author of the memoir The Two Kinds of Decay and other books. Laura Miller is the author of The Magician's Book and is the book critic at Salon. Meghan O'Rourke is the author of Halflife: Poems and is a founding editor of DoubleX. Ed Park is the author of Personal Days and is a founding editor of The Believer. Emre Peker is a contributor emeritus to The Millions. Arthur Phillips is the author of The Song is You and three other novels. Nathaniel Rich is the author of The Mayor's Tongue and is a senior editor at The Paris Review. Marco Roth is a founding editor of N+1. Andrew Saikali is a contributor to The Millions. Mark Sarvas is the author of Harry, Revised and is the proprietor of The Elegant Variation. Matthew Sharpe is the author of Jamestown and other works of fiction. Gary Shteyngart is the author of Absurdistan and The Russian Debutante's Handbook. Joan Silber is the author of The Size of the World. Martha Southgate is the author of Third Girl From the Left and other books. Lorin Stein is a senior editor at Farrar, Straus and Giroux. Felicia Sullivan is the author of The Sky Isn't Visible from Here and is the founding editor of Small Spiral Notebook. Jean Thompson is the author of Do Not Deny Me and other books. David Ulin is book editor of the Los Angeles Times Amanda Eyre Ward is the author of Love Stories in This Town and other books. Dan Wickett is executive director and publisher of Dzanc Books. John Williams is founding editor of The Second Pass Anne K. Yoder is a contributor to The Millions. Todd Zuniga is the founding editor of Opium Magazine Methodology Each panelist could name up to five books available in English with an original-language publication date no earlier than Jan. 1, 2000. We then tabulated the votes of our panelists, along with those of our contributors. Books were ranked according to number of votes received. In the few cases where more than one book received the same number of votes, our contributors, believing firmly that ties are like "kissing your sister," voted to break them. Best of the Millennium, Pros Versus Readers

A Year in Reading: Benjamin Kunkel

Benjamin Kunkel is a founding editor of N+1 and the author of the novel Indecision. His wriiting has appeared in The New York Review of Books, The Nation, and The Believer.There's a Donald Barthelme story that begins (roughly), "I thought I had understood capitalism. But I had only adopted an attitude - melancholy sadness - toward it." My understanding of capitalism improved enormously, though my sadness and alarm did not abate, when last spring I read David Harvey's The Limits to Capital, which was first published in 1981, and was reissued by Verso a few years back. Limits is an effort to square Marx's account of industrial capitalism with an understanding of the sort of financial capitalism that was just beginning to take off, in the UK and the US, back in 1981, and that by the time the rolling disasters of this past fall got underway had become the dominant feature of the American economy. There are many brilliant and persuasive parts of Harvey's book, but in the current context none of them is more striking than his analysis of rent - i.e., housing and land prices - as a form of "fictitious capital." (Which was Marx's term for a claim on future revenue when treated as an asset.) Everyone now knows that real estate prices had gotten badly out of alignment with income, but it takes someone like Harvey to show how property market bubbles (and credit bubbles generally) aim to solve and in fact end up exacerbating deep structural problems with capitalist development per se. The book is also pretty majestically written, in a dry cool analytical way. I think even someone unsympathetic to Harvey's ideas would have to concede the book is an outright masterpiece.More from A Year in Reading 2008

A Year in Reading 2008

The distractions of a good book have been in high demand this year. A quiet corner and a transporting story offered a reprieve from relentless campaign news not to mention cheap entertainment for the many feeling a sudden impulse for thriftiness. 2008 was a loud year, and this final month seems likely to be only more deafening. The annual shopping frenzy has already ramped up, this year with overtones of desperation and the macabre.Yet in the spirit of the season (though in defiance of the prevailing mood), we offer a month of gifts - collected with the help of many generous friends - to our readers. There will be plenty of lists in the coming days assigning 2008's best books (and movies and music and everything else you can think of), but it is our opinion that these lists are woefully incompatible with the habits of most readers. As it does with many things in our culture, what we call "the tyranny of the new" holds particularly strong sway over these lists. With books, however, it is different. We are as likely to be moved by a book written 200 years ago as we are by one written two months ago, and a list of the "Best Books of 2008" feels fairly meaningless when you walk down the aisles of your favorite bookstore or library.Being a reader is about having millions of choices, and a lucky reader has trusted fellow readers as her guides. With this in mind, we've asked a number of our favorite readers (and writers and thinkers) to be your guides for the month of December, with each contributor sharing with us the best book(s) they read in 2008, regardless of publication date. And so we present to you our 2008 Year in Reading, a non-denominational advent calendar of reading recommendations to take you through to the end of 2008.We're doing it a little differently this year. The names 2008 Year in Reading contributors will be unveiled one at a time throughout the month as we post their contributions. You can bookmark this post to follow the series from here, you can just load up the main page for more new Year in Reading posts appearing at the top every day, or you can subscribe to our RSS feed and follow along in your favorite feed reader.Stephen Dodson author of Uglier Than a Monkey's Armpit, proprietor of LanguagehatNam Le author of The BoatBenjamin Kunkel founding editor of N+1 and author of IndecisionRosecrans Baldwin founding editor of The Morning News and author of You Lost Me ThereHamilton Leithauser lead singer of The WalkmenMark Binelli author of Sacco and Vanzetti Must Die!Dan Kois founding editor of VultureAmanda Petrusich author of It Still MovesJoseph O'Neill author of NetherlandRex Sorgatz of Fimoculous.com.Elizabeth McCracken author of An Exact Replica of a Figment of My ImaginationJoan Silber author of Ideas of Heaven and The Size of the WorldAnder Monson author of Other ElectricitiesDon Lee author of Wrack and RuinTraver Kauffman of Black GarterbeltBuzz Poole author of Madonna of the ToastEdan Lepucki of The MillionsJim Shepard author of Like You'd Understand, AnywayPeter Straub author of seventeen novelsRachel Fershleiser co-editor of Not Quite What I Was PlanningCharles Bock author of Beautiful ChildrenEdward Champion of The Bat Segundo Show and edrants.comHelen Dewitt author of The Last SamuraiManil Suri author of The Age of ShivaCharles D'Ambrosio author of The Dead Fish MuseumChristopher Sorrentino author of TranceWells Tower author of Everything Ravaged, Everything BurnedLawrence Hill author of Someone Knows My NameJohn Wray author of LowboyEd Park founding editor of The Believer and author of Personal DaysSarah Manguso author of The Two Kinds of DecayKrin Gabbard author of Hotter Than ThatJosh Henkin author of MatrimonyJosh Bazell author of Beat the ReaperBrian Evenson by The Open CurtainCarolyn Kellogg of Jacket Copy and www.carolynkellogg.comHesh Kestin author of Based on a True StoryScott Esposito editor of The Quarterly Conversation and proprietor of Conversational ReadingGarth Risk Hallberg author of A Field Guide to the North American Family: An Illustrated Novella, contributor to The MillionsSana Krasikov author of One More YearSeth Lerer author of Children's Literature: A Reader's HistoryLorraine López author of The Gifted Gabaldon SistersAnne Landsman author of The Rowing Lesson and The Devil's ChimneyMark Sarvas author of Harry, Revised and proprietor of The Elegant VariationBrad Gooch author of City PoetKyle Minor author of In the Devil's TerritoryChristine Schutt author of Florida and All SoulsTodd Zuniga founding editor of Opium MagazineDavid Heatley author of My Brain is Hanging Upside DownV.V. Ganeshananthan author of Love MarriageFrances de Pontes Peebles author of The SeamstressLaura Miller cofounder of Salon.com author of The Magician's Book: A Skeptic's Adventures in NarniaDustin Long author of IcelanderMaria Semple author of This One is MineRob Gifford of NPR, author of China RoadJohn Dufresne author of Requiem, MassMatthew Rohrer author of Rise UpMickey Hess author of Big Wheel at the Cracker FactoryGregory Rodriguez author of Mongrels, Bastards, Orphans and VagabondsDavid Ebershoff author of The 19th WifeTim W. Brown author of Walking ManPablo De Santis author of The Paris EnigmaHugo Hamilton author of DisguiseJoshua Furst author of The Sabotage CafeKevin Hartnett of The MillionsRoland Kelts author of JapanamericaNikil Saval assistant editor at n+1The Year in Reading RecapBonus Links: A Year in Reading 2007, 2006, 2005

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.
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