Two hidden stories by two famed authors written decades apart in two countries eventually became widely known. One, Anton Chekhov’s, At the Pharmacy, was translated into English in 1998, about one-hundred years after it was published in Russia. The other, Raymond Chandler’s, It’s Alright–He Only Died, was unearthed from its unpublished state by Strand Magazine in 2018, about sixty years after it was written. Though written in different times, and using different scenarios, both stories warn of the barrier money creates to urgent and necessary health care, and of the corrosion in professionalism it causes in providers. They tell of what was to become a defeating feature of Western health care because of financial incentives, social prejudices, and human folly.

Six Kopecks or Your Life

Peter Constantine reached back from the 1990s into the 1880s to assemble a translated anthology of some Chekhov short stories not available to English-speaking audiences. Among the chosen stories in The Undiscovered Chekhov: Thirty-Eight New Stories, is At the Pharmacy.

The story begins when Egor Alexeyitch Svoykin becomes sick. His physician prescribes medicine that a pharmacy would need to prepare. Svoykin felt some relief being in a large Russian city during the late nineteenth century that would have pharmacies he could count on. This feeling of relief dissipated just after entering the pharmacy and coming before the imperious pharmacist there. 

The pharmacist eventually raises his head from a newspaper, looks at the prescription, shouts instructions to his assistants, and then returns his gaze to the newspaper while at the same time informing Svoykin the prescription will be ready in an hour. Svoykin is the only person waiting at such a late hour as it was, and he was deteriorating.

His mouth was on fire; there was a drawn-out pain in his arms and legs; foggy images tumbled about like clouds and shrouded human figures in his heavy head. He looked as if through a veil at the pharmacist, the shelves of jars, the gas burners, and the cabinets. The monotonous pounding in the marble mortar, and the slow ticking of the clock seemed to him to be coming not from the outside but from inside his head. (p. 129)

When Svoykin reports to the pharmacist that he is becoming feverish and feeling weaker, “the pharmacist “remained stock-still and, leaning his head farther back, kept on reading his newspaper. He didn’t respond to Svoykin with word or movement—it was if he hadn’t heard him.” (p. 130) When Svoykin subsequently approaches the pharmacist pleading with him to hurry the prescription, the pharmacist again brushes him off saying, “It’ll be ready soon enough…excuse me, but there’s no leaning on the counter.” (p. 131)

The next half hour was “unbearable” before the prescription came and then made more so by the dubious rituals the pharmacist performed in adorning the prescription container. The pharmacist charged one ruble and six kopecks, but Svoykin was short the six kopecks. 

Under the circumstances…I would be grateful if you would let me bring you, or maybe send you, the six kopecks tomorrow…

I’m sorry, we don’t accept credit here.

What am I supposed to do?

Go home, get the six kopecks, and then you can have your medicine.

But…I’m having difficulty walking, and I don’t have anyone I can send…

That’s your problem.

pp. 132-133

Svoykin returned home, though with difficulty. The Kopecks were there on the table, but his illness kept him from returning to the pharmacy.

Just Drunk

Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes an unpublished Raymond Chandler short story. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective, Phillip Marlowe. This story, however, written between 1956 and 1958, is about a person brought to a hospital emergency room and denied service for financial and social reasons.

As the story opens, a man who has been hit by a truck is brought into the emergency department at General Hospital. He arrives just before shift change and so the admitting clerk is already annoyed about having to assess him. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. Off the patient goes.   

The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. “It’s all right—he only died.”

Fast Forward

If they could have foreseen the current time when they wrote these stories, 140 years ago for Chekhov and 70 years ago for Chandler, they would have realized that the scenarios they created became commonplace and institutionalized in many ways.

Pharmacists may not go unseen behind a newspaper as Chekhov’s pharmacist did, but they may be buried under insurance company paperwork or piles of prescriptions needing to be filled. And certainly in a few situations, perhaps only independents, do pharmacists have ways to cover costs when patients are short on cash, credit, or insurance coverage. They are very likely to send patients away to get money even when they are very sick.

Hospital personnel do not now actually reach into the pockets of unconscious patients to see if there’s enough cash for admission as Chandler conjures in his story, but he would see them still check for money in the form of insurance cards or proof of sufficient financial means. He would also see that the scenario he described in which patients without money get transferred to county hospitals had progressed to a degree that people are moved around among different health care providers based on health care insurance plan coverage or lack thereof. But the poor treatment of patients in need of emergency care can even occur in the “right” hospitals when they are held for hours to days in hallways or holding wards for beds to become available.

Scenarios such as these can and have been addressed to varying degrees through government welfare programs, regulatory requirements, technology advances, and professional practice standards among other responses. The two stories, though, also expose human folly not so amenable to these actions. What can be done about the pharmacist who won’t put the newspaper down to address the needs of a person seeking help for an acute illness? What can be done about the physician who after a cursory evaluation brushes off an unconscious patient as “just drunk?”

Chandler makes an attempt at addressing the human folly he and Chekhov reveal by describing how it fails humanity on both professional and personal levels, and in shaming the character, who is ostensibly standing in for those behaving as this doctor in the story did.

All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it?  Should it?  

Chekhov and Chandler are perhaps hoping that those in the care of others will exhibit more humane and professional behaviors when they ask themselves many decades later: “Am I a doctor?”“Am I a pharmacist?” “Am I a human being?” Would it make a difference? Should it?

Notes

Title image:
A young girl waiting for a pharmacist to make up a prescription.
Photogravure, 1912, after J. Jendrassik, 1896
Licensed under the Creative Commons Attribution 4.0 International

End image:
Nurse Aide Rocky FordHospital CO
Mennonite Church USA Archives, No restrictions, via Wikimedia Commons

Back when I was doing my internship at Pennsylvania Hospital, I was so surrounded by history I felt like I was working in a museum. Even the china we dined on in the hospital cafeteria sported the original historic pattern. And when we finished our training, a brass plaque with our names went up on the same wall as the plaques of our predecessors going back to the 18th century.

At the time, none of this was widely known. But fortunately, Pennsylvania Hospital now has an actual museum, open to the public just in time for the nation’s 250th anniversary. The Pennsylvania Hospital Museum is compact yet chock-full of art, architecture, artifacts, and documents, and has at once become a must-see destination in Philadelphia.

Although Bellevue Hospital has roots that go back to 1736, it started out as an almshouse. Pennsylvania Hospital was the first institution in the colonies founded specifically as a hospital, established in 1751 by Benjamin Franklin and Thomas Bond. The 1756 building housing the museum is a National Historic Landmark. Not only is it considered an important example of Georgian architecture, but its cornerstone even bears an inscription by Franklin referring to King George II.

The landscaped grounds are a serene oasis in the middle of Philadelphia’s Society Hill neighborhood and include a Physic Garden containing herbs and plants used for medicines in the 18th century.

As one enters the building, the first room encountered is the pharmacy, which remained in use until 1927 and now contains interactive displays. A fire engine purchased in 1803 sits in the foyer at the base of a grand staircase. After ascending to the second floor, visitors enter America’s first medical library, a handsome wood-paneled room containing more than 13,000 volumes from floor to ceiling, including one of the nation’s most complete collections of medical books published between 1750 and 1850.

The third floor houses the nation’s oldest surgical amphitheater. In the era before electricity, it was illuminated by skylight, so surgeries could only be performed on sunny days. (I must confess that we interns used to sneak into this room when on call. It was spooky in the middle of the night!)

For me, as a psychiatrist, the highlights of the museum were the exhibits on mental health. I have previously written in MedHum about Benjamin Rush, often called the father of American psychiatry, whose portrait is on view here. Rush served on the staff at Pennsylvania Hospital from 1783 until 1813 and was known for his groundbreaking and humane treatment of the mentally ill. Metal shackles once used as restraints are also on display, although hopefully they predated Rush’s tenure.

Another psychiatric pioneer whose portrait hangs in the museum is Thomas Story Kirkbride, who came to Pennsylvania Hospital for residency training in 1834. When the psychiatric wards exceeded capacity and a satellite facility was built on 101 acres in West Philadelphia, Kirkbride was named superintendent. His ideas about the layout and design of mental institutions became highly influential, leaving an imprint on hospitals throughout the country.

Initially called the Pennsylvania Asylum for the Insane, the new campus eventually became known as the Institute of Pennsylvania Hospital. I completed my residency training there, but over time it was no longer financially viable, and it closed in 1997.

How fascinating to learn that Francis Scott Key, of “The Star-Spangled Banner” fame, wrote a poem titled On Visiting the Pennsylvania Hospital. And to see 18th-century anatomical casts used for teaching at a time when formal dissection was illegal.

There is so much history in this museum that I could not absorb it all in one visit. With its addition, Philadelphia further demonstrates its role as the cradle of American medicine. Indeed, one would have to travel to London to find a larger assemblage of medical historical sites.

In one very busy day—or a more leisurely two-day trip—a visitor can now experience this museum, plus the College of Physicians of Philadelphia and its famous Mütter Museum, while also stopping to see The Gross Clinic by Thomas Eakins. (The painting alternates between the Philadelphia Museum of Art and the Pennsylvania Academy of the Fine Arts, but will spend 2026 at the latter.)

Bravo, Philadelphia!

Benjamin Rush:  Reflections from a Psychiatrist 

Guy Glass 09.02.24 0

A founding figure in American psychiatry, known for pioneering reforms, but also controversial for his treatments and complex contradictions in beliefs and practices.

For more information about the museum, visit Pennsylvania Hospital Museum.
Web image from Wiki Commons

A Most Unexpected Path Laid by a Most Unexpected Disease

Dr. Ross Slotten chose family medicine to serve patients from cradle to grave. But, as he was entering practice, the AIDS virus was entering the community where his practice was situated, and he found himself serving patients much closer to the grave than the cradle. 

In June 1981, a few weeks before I began my internship in family practice [at Saint Joseph Hospital in Chicago], the Center for Disease Control in Atlanta had published the first report of a strange lethal infection among a cohort of gay men in Los Angeles. I had no clue then that the disease would soon kill friends, former lovers, colleagues, and patients; devastate tens of millions of people and their families worldwide; and consume my entire professional life and more than half my chronological one. (p.14)

From both the circumstance of time and place he found himself in, and the sense of necessity and compassion that claimed him, Slotten’s professional trajectory unexpectedly shifted away from traditional family medicine towards specializing in AIDS. His interest in AIDS, however, extended to personal considerations, because as a gay man, he was part of the population at risk, and harbored the same anxieties and fears he saw in his patients and throughout his social circles. His patients were principally gay men because of his geographic location in an established gay community and the resulting referral patterns. The book chronicles both his experiences as a physician taking care of gay men with AIDS, and his experiences as a gay man at risk for AIDS. For Slotten, these experiences were not independent of one another, which makes for rich insights on the complexities of both. 

Slotten spent a lot of time at Saint Joseph Hospital because his patients required intense medical support and specialized services. He tells how he and his practice partner pushed for establishing a specialized AIDS unit in the hospital. They bumped up against usual bureaucratic obstacles, plus a few more concerning issues specific to AIDS patients, but they ultimately prevailed. Slotten “was to spend the next fifteen years there, often heartbroken, occasionally inspired.” (p. 109) In contrast to his commitment, he recounts how some specialists he called for help with particular patients refused when told they had AIDS. Those occurrences stuck with him: “I couldn’t forgive those other physicians for abandoning me and my patients in the hours of our greatest need.” (p. 108)

With whatever little time he had left for volunteer and advocacy work, Slotten stayed local. He talks about the volunteer-run health clinics where he worked (e.g., the famed Howard Brown Clinic), and the housing facility he helped set up for homeless people with AIDS. He left protesting at the Food and Drug Administration, the National Institutes of Health, and the annual International AIDS Conference to others while he focused on his patients, his studies, his volunteer work, and his own safety.

The 2020s are approaching when Slotten writes about the preceding three-and-a-half decades. As he finishes the book he is still caring for people with HIV, but the horrible complications of AIDS are now infrequent since the availability of effective medications. His practice had been reliably stable and predictable for some time, a circumstance he could only dream of when he first started. That dream ended abruptly just as the book was released on July 15, 2020: Covid was surging.

Moments of Horror, Relief, Calm, and Then…

Slotten’s perspectives correspond with the trajectory of AIDS over the thirty-five years his memoir spans. Particular periods are discernable, beginning when gay men were presenting with illnesses associated with profound immunodeficiency of unknown cause. Another is the time of peak AIDS death and destruction represented by the moment in 1992 when Slotten hears from the Chicago Board of Health, “that no one had signed more death certificates in Chicago than I had.” (p. 122) The next moment arrives at the turning point when highly active antiretroviral treatment (HAART) became available, transforming HIV/AIDS for him “from a universally fatal disease…into a chronic one like diabetes…it was almost beyond belief.” (p. 186) Then the prolonged period of relative calm when AIDS became controllable—even preventable—with Slotten noting during a moment in 2016 that, “It had been almost a decade since I’d cared for someone with advanced HIV infection, and I hadn’t lost a patient to AIDS since 2004.” (p. 202)

The AIDS epidemic is known for and measured by the number of deaths that occurred. Slotten wants us to remember the misery the disease causes.

For those who didn’t experience that terrible time, or who’ve forgotten how terrible it was, let my chapters serve as a warning to the complacent and the ignorant: untreated HIV is as ruthless as any terrorist and as destructive as a nuclear device. (p. 3)

He drives this point home when he recounts the stories of individual patients tortured by Pneumocystis carinii pneumonia, Kaposi’s sarcoma, cytomegalovirus retinitis, herpes simplex infections, cryptosporidium dysentery, AIDS wasting syndrome, AIDS dementia complex, and progressive multifocal leukoencephalopathy among other medical horrors, and who often suffer many at the same time. And, all the while, he had little to offer but his wits and his compassion. 

Both attributes would be called upon again in 2020 as Covid struck. Though those with Covid did not produce nearly the fatality rate of AIDS, not nearly the severe comorbidities of AIDS, not nearly the stigma and prejudice as AIDS, and not any of the governmental insouciance seen with AIDS, it still caused a lot of death, suffering, grief, and misinformation at a time when only supportive care was available. Like AIDS, though, the Covid pandemic was transformed into a manageable syndrome with the availability of an effective vaccine, new antiviral agents, and better clinical management regimens.

Complacency remains a threat to the reemergence of any infectious disease. Indeed, AIDS is reportedly rising in poor and developing countries in 2026 as funding for AIDS treatment and prevention programs has been withdrawn from donor countries, mostly that from the United States. Lessons from Slotten’s book may thus be called upon again.

Notes

Book citation:
Slotten, Ross A. Plague Years: A Doctor’s Journey through the AIDS Crisis. University of Chicago Press, 2020. 224 pages

Plague Years is a good companion to the documentary film, 5B, which reports on how San Francisco General Hospital coped during the early years of the AIDS epidemic, and Rebecca Makkai’s novel, The Great Believers which features the stories of a group of gay men in Chicago also during the early years of the AIDS epidemic.

Dr. Slotten was a guest on an episode of The Clinic & The Person podcast to discuss his experiences during AIDS epidemic as he reported them in his book, and how well they match up with what we see in 5B and read in The Great Believers.

Web image by Medhum.org

Out of the gay rights activism in the 1970s came AIDS activism in the early 1980s. By then, the incidence and severity of AIDS had become evident and caused enough fear to generate social backlash against those with the disease. This, along with federal government insouciance at the time, made it necessary for gay rights activists to extend their remit into advocacy for health care specialization and research advancements for AIDS. The expanded activism was visible on the streets and at governmental research institutions (e.g., National Institutes of Health). Where it was also taking place, and not in such an obvious way, was within certain hospitals.  

San Francisco General Hospital answered the call first in 1983 when it created a special unit for the care of people with AIDS in “Ward 5B.” The unit was in operation through its move in 1986 into Ward 5A to accommodate more patients, and until 2003 when advances in antiretroviral treatment of AIDS made the unit no longer necessary. But throughout, the struggle to maintain and advance the unit medically, socially, and politically persisted. The documentary film, aptly named “5B,” covers the struggles, successes, and failures of the unit, and the activism required of the staff and advocates for its creation and ongoing viability.  

From the Inside 

The story is told from various perspectives through interviews with key figures in the unit’s development and operation, and with archival footage of the unit and AIDS activism in the community. The most prominent among the key figures is Cliff Morrison, a clinical nurse specialist who spearheaded the idea for the unit and then managed it. Several other nurses who served in staff and supervisory positions are also featured. Participating physicians include Paul Volberding, an oncologist at the time who became pivotal in the development of effective HIV treatments, and Julie Gerberding, a physician treating patients on the unit who later became the Director of the Centers for Disease Control (CDC). Lorraine Day, the chief of orthopedic surgery at the hospital when the unit opened, is heard often as an opposing voice. Hank Plante, a local television news reporter, also appears frequently to offer his perspectives on many of the social and political issues swirling around the unit. Among other participants are AIDS activists, volunteers, and family members of unit patients. 

Several storylines frame the documentary including how nurses drove the unit’s inception and then were instrumental in running it. “Nurses were in charge,” said Volberding, admiringly. Interwoven throughout the film are the experiences of the patients and individual nurses, including one nurse who was infected with HIV from a needle stick. “Those nurses were the real heroes,” said one activist.    

Rare is the story, though, about heroes who aren’t confronted with daunting challenges, and thus this documentary includes a storyline involving attacks the unit nurses encountered from inside the hospital. The nurses of this unit practiced in ways they considered safe but not in such a manner that would preclude them from touching patients or require them to don so much protective gear they become unseeable. Nurses and clinicians from other units objected and did not want to be compelled to adopt practices they thought endangered them on the occasions they took care of AIDS patients. The film follows this story through union grievances and public debates to their conclusion, which sided with the unit nurses and their advocates. The spirit of activism among the unit staff was pivotal in fending off the many challenges they faced. 

Keeping in Touch 

The documentary reveals stark juxtapositions that can manifest in the midst of an infectious epidemic, and in particular when an epidemic selects an identifiable group that is unwelcome in mainstream society. Two juxtapositions that stand out are the emotion of love with that of fear, and those who are deemed worthy with those who are considered disreputable. 

No treatments for the HIV infection or for the many horrid and lethal diseases resulting from AIDS were available when the unit opened—it was “a very, very unpleasant death” as one nurse put it. The nurses saw a big part of their role as offering love: “Here you were allowed to love your patients.” They offered it through human touch. Morrison’s view was, “If we can’t save these folks, we’re going to touch them.” To touch the patients in this way required that they balance it with the risk of exposure to infection and still comply with universal precautions. Nevertheless, fear was prevalent—some people were “truly hysterical” according to Gerberding—and it touched off conflict among the health care staff. “People were afraid…we found ourselves attacking each other…everyone was so stressed,” is how Volberding described the situation. This balance is one that is continuously negotiated in health care settings, but it was more pronounced during the early years of the AIDS epidemic, and at San Francisco General, it had to be mediated by hospital and union officials. 

At the time unit opened, and for a long while after, people with AIDS were scorned. The gay lifestyle was linked to the disease and so a view held by many was that the gay community deserved to be struck down by this plague. They were not worthy of all the human resources, technology, and money the disease required. The documentary brings this sentiment to life by showing the actions some people took to prevent getting these patients help, and the actions governments didn’t take to help them. Also shown, however, was how the activism of health care professionals and others in Ward 5B helped to overcome these obstacles. Without it in the case of the unit in Ward 5B, the activism in the streets outside the hospital alone may not have been enough.  

But Then 

These fevers abated some when medical advances produced treatments that obviated the need for AIDS units, and changes in societal attitudes led to more acceptance of gay lifestyles. The next epidemic that targeted marginalized and susceptible groups would determine whether lessons learned from the time of this unit had been incorporated in response protocols. That opportunity came the year this documentary was released in 2019 when Covid struck elderly people first and hardest, and especially those in communal living arrangements.  

Note: 

The documentary was featured on the podcast episode, How Terrible It Was: Three Takes on the AIDS Crisis with Dr. Ross Slotten, which can be accessed here on medhum. In addition to the documentary, the podcast episode included the novel, The Great Believers, and the memoir, The Plague Years: A Doctor’s Journey through the AIDS Crisis were discussed. The author of the memoir, Dr. Ross Slotten, joined the podcast as a guest. 

Title image credit: 
James Steakley, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons 

Documentary information: 
Film title: 5B
Directors: Paul Haggis, Dan Krauss 
Studio: Vertical Entertainment 
Viewing source: Amazon Prime 
U.S. release date: June, 2019 
Run time: 134 minutes  

Trailers from 5B Film

If there was ever an ironic title for a book about the best ways of achieving a long and healthy life, it’s this one: Eat Your Ice Cream. That’s because a major conceit of the book is that if we are to incorporate all the recommendations for achieving good health into our lives, some balance—tradeoffs—will be necessary. Eating ice cream exemplifies that balance: when consumed in moderate amounts, it offers some nutrients and a lot of happiness.  

The author, Dr. Ezekiel Emanuel, known to all in his many circles by the mononym “Zeke” (think: Sting, Prince, Oprah), points to a couple of motivations for writing the book. One is in the service of his life-long quest to “improve Americans’ health.” (p. 11) He has gone about this in many ways including his service as a medical oncologist, chief of the National Institutes of Health Bioethics department, medical school professor, health policy researcher, author of many books and articles on a range of health care subjects, and as an architect of the Affordable Care Act (aka, “Obamacare”). His other motivation arises from his view that current wellness advice makes it “nearly impossible to differentiate the valid, reliable, and effective from the speculative, deceptive and just plain stupid.” (p. 4). His aim, then, is to “provide a concise, clear, and authoritative synopsis of what health experts know works best to bring the biggest health benefits—without extraneous, speculative, or absurd additions.” (p. 11) 

Getting a Six Pack 

Running through the book is Zeke’s insistence that wellness behaviors and practices will be most effective when they become part of daily life and not something separate or extracurricular, and as such wellness rules “become an invisible part of lifestyle, sustained by habit.” (p. 10) He gives himself the task of cutting through the jungle of wellness advice and providing “a distillation of the evidence to simplify doing the right thing” for a healthy life. (p. 9) 

In keeping with his theme of simplicity, he breaks down wellness advice into “the six wellness behaviors that yield the maximum benefits with the least work.” (p. 9) They are: 1) avoid self-destructive behavior; 2) cultivate family, friends, and other social relations; 3) stay mentally healthy; 4) consume healthy food and drink; 5) exercise well and regularly; and 6) get the rest you need. He hastens to add that these six behavior categories reflect the thinking of ancient times among Greeks, Chinese, and Indians.  

Each of the wellness behavior categories constitutes individual chapters. In each, Zeke covers both obstacles to attaining good health (e.g., heavy alcohol consumption) and practices that facilitate attaining good health (e.g., getting vaccinated). His recommendations are based on evidence from credible sources and are time tested. He presents them in more of a conversational form in plain language and not much in the way of strict protocols or mechanical algorithms.  

While Zeke considers all six wellness behavior categories crucial to a healthy and long life, he does not rank them in importance or priority. He does, however, form two groups from them and makes a distinction between the two, noting that “risk management, friendship and social interactions, and mental engagement have a measurably greater impact on your wellness than diet, exercise, and sleep.” (p. 8) This may come as a surprise to hardcore health advocates who put a major emphasis on, if not obsess about, exercise, diet, and sleep. Zeke goes further to say about the zealots: 

They ignore the importance of family, friends, and social relations—the emotional wellness behaviors—which have a remarkable impact on the quality and length of one’s life. And it’s a dangerous fallacy that a deficit of emotional wellness behaviors can be remedied with a surplus of physical wellness behaviors. No amount of kale or number of steps or hours of sleep can replace the importance of building and maintaining good relationships for wellness and longevity.  
(p. 54) 

He comes back repeatedly to the greater importance of social over physical components for good health. He seems a bit obsessed with it, though convincingly so.  

Neither Extremist nor Scold 

Distinguishing this book from others in the field is how Zeke does not scold people to abandon all behaviors that can work against achieving a healthy life, nor does he advocate people push themselves to extreme levels of compliance and sacrifice. Neither is sustainable and both can result in futility and abandonment. He urges us to find the mix of behaviors and levels of commitment that can be woven “into the fabric of your everyday life so they become automatic and easy, not a chore, burden, or all-consuming fixation. (p. 187) 

Zeke offers ways to moderate specific recommendations or to make trade-offs. One example is alcohol consumption. He realizes that although alcohol should be avoided, that’s not likely. When it can’t, he advises that people at least not drink alone because some of the risks of a daily drink “is probably outweighed by the benefits of time with friends.” (p. 34) As another example, Zeke advises that exercise is essential, but when excessive, diminishing returns can result. “Exercising 2 or 3 hours a day will not improve your longevity more than 45 minutes a day.” (p. 164) Furthermore, in this regard, he says, “There’s something to be said for living fully and being present, not constantly monitoring our activity tracker or feeling guilty for not achieving every wellness goal.” (p. 10) Don’t obsess, and toss the wearables.  

So, go ahead, eat your ice cream, but not too much, and do it with family and friends. Then walk home safely and get a good night’s sleep.  

Photo attributions: 

Hubert Opperman eating an ice cream next to a Peter’s Ice Cream Reo truck, 1936 
Sam Hood  
State Library of New South Wales collection, No restrictions, via Wikimedia Commons 

Melba Phillips Eating Ice Cream 
Emilio Segrè Visual Archives  
CC BY-SA 4.0, via Wikimedia Commons 

Modern medicine’s emphasis on extending the human lifespan has, in some cases, transformed dying, once a communal and spiritual event, into a cascade of arduous procedures. Deftly synthesizing the wisdom of many experts with his own insights and experiences, Palmer offers compelling, accessible, and refreshingly honest advice on how to shape our lives and legacies so that we are better prepared to die as we see fit—highlighting agency in aging in the face of ageist norms. 

Just last week, New York Governor Kathy Hochul announced that the state will join 11 others and Washington, D.C., in legalizing medical aid in dying (MAID), or when physicians prescribe a lethal dose of medications to patients with fewer than six months to live. 

“New York has long been a beacon of freedom,” Hochul said, “and now it is time we extend that freedom to terminally ill New Yorkers who want the right to die comfortably and on their own terms.” 

The governor’s rhetoric emphasizes a collective cognitive dissonance: As physician (and fellow politician) Dan Morhaim observes, “our culture celebrates personal autonomy,” but when it comes to death and dying, “we collectively abdicate” that value. 

Citing Morhaim and others, Palmer provides valuable context for our relationship with mortality (along with additional information about MAID). During the nineteenth and early twentieth centuries, the average death was relatively quick and happened at home, with little involvement from healthcare providers and medical technology. Today, dying is protracted and tends to take place in hospitals or nursing homes; healthcare providers and medical technology are highly involved; and life can be prolonged with organ transplants, chemotherapy, and more. 

“There is a significant difference between dying peacefully in your bed at home and dying yoked to tubes and machines in an ICU,” Palmer writes, “receiving futile care that only prolongs the dying process for perhaps a few days while providing a horrendous quality of life.” 

Drawing on surgeon Atul Gawande’s [1] work, Palmer argues that, at best, physicians are uneducated about aging and dying and what might matter to patients approaching the end of their lives. At worst, they are financially motivated to perform aggressive interventions that may do more harm than good.  

According to numerous studies, frail patients do poorly in hospitals, and Palmer points out that doctors nearing death tend to eschew the very treatments they give to their older patients, such as surgeries and radiation. 

“I don’t want my last conscious thought to be of doctors stabbing needles into my veins, my ribs breaking from chest compressions, and a large-bore tube thrust into my throat and lungs,” the end-of-life activist writes. “When a patient is young and robust, such curative measures may make good sense despite their violence, but not for an old, debilitated, frail patient.” 

But we have choices: “where to die, how much treatment to have, and how to spend the limited time we have left.” 

“While, in a real sense, no death is ever ‘good,’” Palmer underscores, “planning and preparation can make death less awful and painful.” 

Legislation to make MAID available to the terminally ill is one step in that direction. However, critics argue that MAID may endanger the elderly and disabled, who might feel pressured to end their lives out of fear of causing hardship to their families. Opponents also contend that such policies reinforce the toxic notion that a life with a disability or chronic illness is not worth living. Also, some individuals may seek MAID due to high treatment costs, but MAID should not substitute for accessible care and support. 

Racial inequities in healthcare are also relevant; Black people might opt for MAID because they are more likely to receive inadequate pain management due to stereotypes that they are drug-seeking or pain-tolerant.[2] Palmer could have engaged more fully with these valid concerns. Fortunately, the Medical Aid in Dying Act in New York has a number of guardrails meant to ensure the patient’s decision is informed and voluntary, including a conflict-of-interest prohibition and a mandatory mental health evaluation. 

Well before we are terminally ill, we need to be having routine conversations about dying with our loved ones and physicians. To that end, Palmer endorses The Conversation Project. He also suggests creating an advance directive, or a legal document outlining your healthcare wishes, and choosing a healthcare proxy—not necessarily your closest relative—when you’re young or in good health. One way to think about your healthcare wishes is to complete the sentence “I would want to live as long as I could still…”, as recommended by physician Eleanor Tanno. Another is to consider an “exit strategy,” or an illness for which you would decline treatment.[3] 

Some other tips from Palmer for a “good” death: 

• Write a personal mission statement; letters of gratitude to loved ones; and legacy letters, also known as ethical wills, that capture your essence, beliefs, and stories to pass on to future generations. 

• Make a folder containing everything your children must handle when you die. 

• Join a “village,” or “virtual retirement community.” 

The author also illuminates the benefits and limitations of palliative and hospice care, delineates various eco-friendly alternatives to embalming (reader: as of writing this, I’d like to be affordably composted), and presents ideas for making funeral and memorial services more substantive—and even fun. 

Achieving a Good Death is a touch dogmatic, but Palmer demonstrates in the book’s rich appendices that he practices what he preaches. In a letter to his family about his own end-of-life wishes, he shares the pain of witnessing his mother’s final years in a nursing home: “I want to prevent what happened to her from happening to me.” 

“If my mental function is seriously compromised with little chance for full recovery, please seek opportunities to encourage death’s approach… Are my kidneys faltering? Let them,” he writes, giving new meaning to author Mel Robbins’ self-help concept. 

The book’s main flaw—one the author himself acknowledges—is that it is primarily aimed at those with friends and families. Readers without such connections may feel less comforted than grimly recognized by Palmer’s planned memorial service playlist featuring the Beatles’ “Eleanor Rigby.” 

Ultimately, Achieving a Good Death is a stimulating must-read for mortals that will leave you equipped for a more peaceful, dignified, and meaningful end. 

Achieving a Good Death: A Practical Guide to the End of Life
Chris Palmer
Rowman & Littlefield, 2024

[1] Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Metropolitan Books, 2014. 
[2] Substance Abuse and Mental Health Services Administration. The Opioid Crisis and the Black/African American Population: An Urgent Issue. Publication No. PEP20-05-02-001, Department of Health and Human Services, Office of Behavioral Health Equity, 17 Mar. 2020, samhsa.gov/sites/default/files/meeting/documents/csap-nac-presentation-03172020.pdf.  
[3] Harrington, Samuel. At Peace: Choosing a Good Death After a Long Life. Hatchette, 2018. 

Web image by Medhum.org.

Directed by Anne Kauffman, the play features “Primes,” or holographic simulations of the dead intended for therapeutic use by the living. June Squibb—who, at 96, is making history as the oldest performer to open a Broadway show—astonishes as Marjorie, an impish 85-year-old with dementia using a much younger version of her husband Walter (an uncanny yet tender Christopher Lowell) to regain and retain her memory. Marjorie’s daughter Tess (the incredible Cynthia Nixon) is skeptical and fearful of the technology, whereas Tess’s husband Jon, played by a standout Danny Burstein, is a fan—until an on-the-nose change of heart in the penultimate scene. 

Marjorie Prime’s central flaw is that it favors concepts over dramatic depth. The characters are well-acted but underdeveloped, and almost all they do is talk; the biggest event may be Marjorie urinating herself. Yet, despite its slow pace and formulaic structure, Marjorie Prime is intelligent and poignant. 

Marjorie’s memories are embellished and sanitized for her comfort and convenience. The fallibility of memory is hardly a novel concept, but the Primes enable this reconstructive process and also become a stand-in for genuine connection in the wake of grief, preventing the family from confronting painful realities and repairing their relationships.  

By the time the truth fully surfaces in the unsettling final scene, which makes adroit use of a stage turntable (props to scenic designer Lee Jellinek), there are no humans left to heal. When storytelling is delegated to AI, truth becomes archival rather than relational; however, truth must be witnessed between living people in order to be ethically and therapeutically meaningful.  

Playwright Jordan Harrison’s Primes, like flesh-and-blood clinicians, absorb and co-construct patients’ accounts of self, yet they are disembodied, unfeeling, and ultimately unable to act with compassion, turning dynamic stories into datasets.   

Marjorie Prime, through Feb. 15 at the Helen Hayes Theater in New York; 2st.com/shows/marjorie-prime.  

“Much of healthcare happens in interpersonal moments,” write Maura Spiegel and Danielle Spencer in the first chapter of The Principles and Practice of Narrative Medicine—and machines are good at many things, but participating in a truly interpersonal moment is likely not one of them. Several studies have suggested that models perform worse for underrepresented groups because they are trained on datasets that lack racial, cultural, and linguistic diversity. Additionally, AI may miss subtle emotional cues and fail to interpret tone, context, and metaphors, which, one bioethicist [1] predicts, could “fundamentally alter” how trust is practiced in healthcare. Others [2] have underscored that “AI should be viewed not as a replacement for the physician, but as a partner in delivering empathetic, patient-centered care.” 

However, AI is not wholly bad. For example, a recent systematic review [3] found that applying natural language processing (NLP) to unstructured text in electronic health records (EHRs) can detect signs of cognitive impairment. Some [4] have found solace in text-based simulations with lost loved ones. And perhaps technology should be viewed as a vehicle for strengthening partnerships between clinicians and patients. Designed by Gabriela Gomes, the video game Healing Spaces aims to help those with neurodegenerative diseases connect with their caregivers. It is a multisensory experience: an app with beach and forest scenes, and a box with aromatherapy that smells like pine trees. Healing Spaces may evoke memories or even create new ones between caregiver and patient, unlike the Primes’ hollow curation. 

Healing Spaces also includes sunscreen-scented lotion that caregivers can use to massage the hands of those in their care. Needless to say, holograms and lotion don’t pair well. “You can’t touch a hologram. So there’s something about them looking so much like your loved ones, but not being able to quite achieve intimacy with them,” said Harrison during Marjorie Prime’s Off-Broadway run about a decade ago. “The loneliness can never be quite extinguished, never satisfied, because they’re just pixels.”  

[1] Kerasidou, Angeliki. “Artificial Intelligence and the Ongoing Need for Empathy,  Compassion and Trust in Healthcare.” Bulletin of the World Health Organization, vol. 98, no. 4, 2020, pp. 245-250. pmc.ncbi.nlm.nih.gov/articles/PMC7133472/. 

[2] Ghenimi, Nadirah, et al. “Integrating AI with Narrative-Based Medicine: Enhancing Patient-Centered Care in Primary Practice.” Perspectives in Primary Care, 5 Dec. 2024, info.primarycare.hms.harvard.edu/perspectives/articles/integrating-ai-with-narrative-based-medicine.  

[3] Shankar, Ravi et al. “Natural Language Processing of Electronic Health Records for Early Detection of Cognitive Decline: A Systematic Review.”npj Digital Medicine, vol. 8, no. 1, 2025, p. 133. pubmed.ncbi.nlm.nih.gov/40025194/. 

[4] Fagone, Jason. “The Jessica Simulation: Love and Loss in the Age of A.I.” The San Francisco Chronicle, 23 July 2021, sfchronicle.com/projects/2021/jessica-simulation-artificial-intelligence/. 

Web image from 2nd Street Theater.

The latter decision unarguably constitutes a significant setback in the struggle for reproductive rights for American women, but the history of access to abortion—and a sense of what the future might hold—may best be understood by taking the long view, across cultures. In Pushback: The 2,500-Year Fight to Thwart Women by Restricting Abortion, historian Mary Fissell does just that. Starting with the story of an enslaved woman in ancient Greece who becomes pregnant after being hired out as a prostitute by her enslaver, Fissell presents a series of case studies. Each one illustrates how women continued to have abortions through the centuries despite changing mores, laws, the influence of the church, and the irregular availability of experienced or qualified providers. The stories also demonstrate a pattern: as women gained more social and economic freedoms, the laws governing abortion became more restrictive, with the pendulum eventually swinging back in the opposite direction to a more liberal stance on abortion.

The enslaved woman in ancient Greece would likely have faced no moral sanction for seeking an abortion—her value lies in her continued availability as a sex worker, and, in her case, a singer. Documents suggest that women in her position would have had the knowledge to end her pregnancy, most likely with an herbal abortifacient, though squatting, jumping and sneezing were also recommended methods of preventing pregnancy immediately after sex. In ancient Rome, the focus on controlling fertility was somewhat different; Roman women had greater freedoms than their Greek sisters, raising concerns about adultery, which Augustus declared as a criminal offense. With  a focus on increasing the number of upper-class Romans who would rule the growing empire, controlling the fertility of elite married women was one way to achieve this end.

Leaving antiquity behind, Fissell nimbly guides us through the Middle Ages. In an era where Christianity is on the rise, and the issue of ensoulment is linked to the experience of quickening (when the pregnant woman first feels the fetus moving), the story of Brigid of Kildare was recorded. Brigid, a holy woman whose historical existence cannot be confirmed, was said to have helped a young woman miraculously end her unwanted pregnancy (a subsequent miracle attributed to Brigid helped a woman preserve her chastity).  The Church’s codified position on abortion was still more than 500 years away and for many of these early Christians, discussions of ensoulment notwithstanding, concerns around abortion as a means of covering up illicit sex appear to have weighed more heavily than any harm to the fetus.

In early modern Europe, in some parts of the continent, abortion had become a capital crime punishable by execution, a development that reflected “a larger cultural shift that sought to control female sexuality in the interests of Church and state.”  The story of Anna Harding who went on trial in 1618 was a case in point. Against the background of a witchcraft panic, Harding  admitted to providing both married and unmarried women with herbal and floral preparations to end their pregnancies. A “confession” under torture to having consorted with a demon led to Harding’s conviction and being burned at the stake. 

Indeed, herbal preparations to end unwanted pregnancies were common to societies as disparate as enslaved women in the Caribbean, who used abortions as an act of resistance, to Victorian women of all classes who sought abortions for many of the same reasons as women do today. Use of one of the herbs best known to induce abortion, pennyroyal, persisted up through the early 20^th century, although not without risk to the pregnant woman.

By this time, the idea that life begins at conception had gained a greater hold in the United States. Hugh Hodge, a professor of medicine at the University of Pennsylvania, argued this “scientifically-based” premise as early as 1839, while the Pope’s 1869 declaration that life begins at conception would have been presented as divine revelation, though Fissell posits that concern on the part of European monarchs in Catholic countries worrying about depopulation and “degeneration” may well have influenced the pronouncement.

The story of Beatrice J, a Baltimore woman, who safely achieved two self-managed abortions in the 1940s through the aid of a catheter and ergot pills to induce uterine contractions, serves as a more modern example of women who had ended a pregnancy going on to administer abortions to others. In Beatrice’s case, after her trusted pharmacist helped set her up as an abortion provider, an undercover police operation exposed her practice. A trial followed, but charges were ultimately dismissed by a progressive judge on the basis that the “client”  who visited Beatrice was not actually pregnant.

In addition, Fissell points out this was not an isolated example by any means. Even in the most restrictive settings and time periods, there appears to have been a fair amount of  tacit acceptance.  In the U.S., for example, “Physicians performed legal abortions for a variety of indications, and the rest, so-called criminal abortions, went largely unremarked. In the 1920s and ‘30s, abortion providers were rarely prosecuted, whether physicians or not, and the former were at risk only if a woman died.” Moreover, once antibiotics and blood transfusions became available in the 1930s and 1940s, the morbidity and mortality associated with these procedures would have been reduced.

The presence of abortion providers who practiced under the radar persisted throughout the ‘30s and early ‘40s, albeit with some providers using their own judgement as to who was morally deserving of their covert services.  But the 1940s and 1950s also brought a more punitive attitude toward abortion in the United States. With an increasing number of arrests of providers administering safe abortions, dangerous practices became more widespread, as did abuses by practitioners, including sexual assault on clients. In turn, these tragic stories led to the underground movement of women and their allies who supported those in need, including the Jane Collective in Chicago, a group of women who risked criminal prosecution to help others obtain safe abortions. 

While the individual stories of women seeking abortions constitute the throughline of Pushback, Fissell consistently addresses the broader factors that affected access in each of the societies she describes, including eugenics, racism, nativism, and concerns about fidelity and heredity. Enslavement and labor demands, the appropriation by physicians in the 19^th century of care that was formerly the domain of midwives, and superstitions linking women’s fertility to fertility of livestock and crops, also come under scrutiny, as does the relatively recent shift of emphasis from the importance of the life of the mother to that of the fetus.

Readers might also consider the role of medical advances as factors that have altered our understanding of pregnancy, development of the fetus, and access to abortion. Among them was the development of simple urine tests that eliminate the uncertainty surrounding pregnancy, a means of confirmation light-years away from those early societies where pregnancy was confirmed by quickening. Sophisticated imaging of the fetus via ultrasound not only confirms pregnancy at an early stage, but packs an emotional punch. Moreover, the availability of medication through pharmacies and online sources for self-managed abortions, while under threat, has created a new landscape for pregnant women. This last means of obtaining an abortion, though formulated in a laboratory, suggests a new iteration of the herbal abortifacients used by so many generations past.

Pushback succeeds at being both highly readable and meticulously researched—the volume includes an extensive list of notes and references for each chapter. Fissell, who is the Inaugural J. Mario Molina Professor in the History of Medicine at Johns Hopkins University, also writes the Substack A is for Abortion: Snapshots from the Past. As a pre-modern historian of the 17^th century, she particularly enjoys the kind of “detective work” that accompanies that study. But she was also pleasantly surprised by how much she enjoyed researching and writing on the modern period, where sources are more readily available, including data she found through Ancestry.com.

Fissell completed her manuscript before the start of the second Trump administration and aside from allusions to Roe v. Wade and Dobbs v. Jackson, Pushback does not explore the ways in which abortion became a flashpoint in our most recent national elections. (A description of politically motivated anti-vice campaigns that targeted abortion practitioners and pregnant women in the late 1940s and 1950s is included in the chapter dealing with that time period.)

But in a discussion with this writer, Fissell weighed in on current data that shows more American women than ever are having abortions despite the 2022 Dobbs ruling. “Restriction has an impact and makes abortion much more difficult and dangerous to access,” she said. “But it never stamps it out.” She also cited data that suggests roughly 66% of Americans think abortion is a decision that should be made between a woman and her doctor.  

Interestingly, Fissell did wonder at the onset of her research for Pushback whether she might change her mind on the issue. In the end, she describes holding the same views as when she started.  “Given that abortion was often shameful and secret if not [completely] illegal, I was amazed by how much I was able find out.” Her appreciation for insights from the reproductive justice movement deepened considerably as well, as it informed her understanding of women in earlier societies and the use of the term “choice,” then and now, for women in untenable circumstances.

“[Choice is] something a white woman with money can afford to have,” Fissell said. “Choice [does not apply to] a struggling waitress in a small Southern town who was raped and has two kids at home, and her wages won’t even cover their care…Casting the decision as choice means we don’t understand many women’s experiences.”     

Pushback by Mary Fissell was published by Seal Press (2025).
Web image by Medhum.org.

Before modern medicine, superstition mediated pregnancy and childbirth. Once, divine wrath or distressing mental images risked what was called a monstrous birth. To reduce risk today, pregnant women consult prophetic prenatal technologies and the ceaseless cacophony of digital media. Twice pregnant, New York Times pop culture and internet reporter Amanda Hess found herself both drawn to and repelled by media advice and the collection of data enticed by apps or insisted on during clinical encounters.  

Her book Second Life: Having a Child in the Digital Age—part wry memoir, part savvy investigative reporting—asks whether current technologies deliver a better, if not perfect, baby or the maternal well-being they augur. She, even more significantly, worries about the consequences, personal, relational, and ethical, of pursuing perfection.  

Hess couldn’t resist interacting with chatty, advice-giving apps. One first tracks her fertility and then, in weekly installments, shows her what a developing “creepily realistic CGI fetus” looks like. (Another app likens fetal development to the temptations on Parisian bakery shelves. A macaron, for instance.) Visual creepiness aside, Hess has unsettling thoughts about surrendering intimate information about her body to unknown recipients. She discovers that a popular app she regularly consults was developed by two brothers in Belarus backed by venture capitalists. Its surveillance exposed her to endless marketing schemes that hardly considered anyone’s well-being or financial resources. Curious about the history of fertility tracking before and after apps, Hess discovers a throughline of troubling eugenic ideologies. It travels through the advice of a popular pregnancy influencer. 

Deep into Hess’s first pregnancy, a “concerning” routine ultrasound detected what could be Beckwith-Wiedemann syndrome (BWS), a rare genetic condition. Its possibility sent Hess anxiously scanning the internet, against her doctor’s advice, for medical information and possible maternal causes. Was it the wine? The Ativan? A fever? Her age? Unspecified guilt followed. But neither the internet, genetic testing, nor her doctor could reassure her about a cause or the possible extent of the condition. The internet images she sought of children with the full range of BWS anomalies hardly quelled her anxieties. Only after her son’s birth was a form of BWS confirmed.  

Hess sympathizes with the wish to deliver a healthy baby and the temptation to seek any available service or technology to that end. After all, that’s what she wanted. However, the prospect of birthing a child with an anomalous body leads her to question the meaning of the ubiquitous parental qualification: “As long as the baby is healthy.” Healthy, she finds, translates to normal. Anticipating a not-normal child makes her feel protective of her son even before his birth. After it, she deflects thoughtless remarks from strangers about his enlarged tongue protruding from his lips. (Corrective surgery later enables less compromised breathing and speech.) She and her husband care for and about him for the distinct person he is. About her initial anxieties about his body, Hess writes, “My nightmare . . . ended when I met my son.”  

Hess’s standout chapter “Growth” recounts her evolving response to her son’s imperfections and her efforts to manage others’ IRL and internet responses to him—a task she finds essential to parenting him. I hope this chapter is widely read, certainly by future parents, but also by clinicians, genetic counselors, and those who teach them.  

Some accounts of caring for an imperfect child cast the child and the parental relationship as special. Some view chronic illness or disability as a familial burden. Hess does neither. Instead, she folds caring for her son into the course of her life and her family’s. In that way, she continues a contribution of Michael Berube’s complicated 1996 Life as We Know It, however, adding a millennial’s navigations of current medical technologies and media static. Hess further envisions a world that participates in the care of all children, one that refuses to blame or isolate families with less-than-perfect children. That world would reduce parental anxieties more than screening for concerning “problems.” Philosopher of care and mother of a profoundly disabled child, Eva Kittay, would agree. 

Some readers might say that Amanda Hess’s financial and other resources make her generous perspective possible. She agrees. She’s half of a two-parent family. As journalists, she and her husband have more flexible schedules than countless other parents. But in the world Hess encourages, parental status would be irrelevant to their child’s care. 

Without being prescriptive, Hess’s lively, self-reflective story provokes readers to think twice about rejecting imperfect children—anyone’s—and to notice the eugenic logic underwriting rejection. Her book tests the claim that ever-evolving technologies enhance maternal well-being, empower parental choice, and guarantee healthy babies. (Ironically, a researcher Hess encountered reported on increasing evidence of BWS in IVF conceptions, many intended to screen for anomalies.) In fact, far more children are permanently harmed during their lives than are born ill or disabled. Rather than relying on the billion-dollar industry of prenatal testing, aren’t we better off, Hess asks, accepting and taking better care of all children however they’re born? 

Second Life: Having a Child in the Digital Age
Amanda Hess  
Doubleday, 2025, 272 pages 

The Knick portrays all that goes on in and around a hospital struggling to provide care for the poorer classes in lower Manhattan during the early 1900s. It shows that many of what were then considered important advances in medicine, technology, society, and culture were later considered dangerous, unethical, barbaric, inhumane, and racist. The series asks whether health care of any era, along with associated social and cultural factors at work, are destined to be seen sometime in the future in similar ways. 

Storylines of the Poor and the Famous 

The Knick was inspired by the Knickerbocker Hospital, founded in Harlem in 1862 to serve the poor. In this twenty-part television series spread over two seasons, the fictional Knick is located somewhere in the lower half of Manhattan around 1900. The time covered during the series is not marked in any distinct way. The characters do not age much, and although fashion and customs remain static during the series, the scope and significance of advancements that come into play were actually adopted over a longer time than the episodes cover.  

The series builds on some known history. The central character, the chief surgeon Dr. John Thackery, is modeled on a famous surgeon of the time, Dr. William Halsted, in both his surgical adventurism and in his drug addictions. The character, Dr. Algernon Edwards, who is an African-American, Harvard-educated, and European-trained surgeon, is based in part on Dr. Louis T. Wright, who became the first African-American surgeon at Harlem Hospital during the first half of the twentieth century.   

Storylines of human drama and folly run through the series. Among them are medical cases both ordinary and bizarre, heroic successes and catastrophic failures, loves won and lost, gilded lives and wretched existences, honor and corruption, racism and more racism. Within these storylines are the scientific, medical, and industrial advances of the period, as well as the social frameworks that form fin de siècle hospital care and medical research in New York City.   

Some of the industrial advances adopted by the hospital include electrification, telephone service, and electric-powered ambulances. We see that transitions to these new technologies are not without risks and catastrophes: patients and hospital staff are electrocuted, and when the ambulance batteries died — a frequent occurrence– many of the patients they carried died, too. 

Medical advances integrated into various episodes include x-rays, electric-powered suction devices, and an inflatable balloon for intrauterine compression to stop hemorrhages. Thackery is a driven researcher taking on some of the big problems of the day, such as making blood transfusions safe, curing syphilis, and discovering the physiologic mechanisms of drug addiction. We see how he learns at the cost of his patients, or rather his subjects. We also get a glimpse of movements directed at population health. For example, epidemiological methods are applied to find the source of a typhoid outbreak, which drew from the actual case of Mary Mallon (aka, Typhoid Mary). Shown juxtaposed to the advances in epidemiology is the concurrent interest that was rising in eugenics and its broad application to control for unwanted individual traits and particular groups of people. Research ethics and regulations were a long way off.  

Time Tells 

Each era possesses its own hubris based on the technological advances and social progress made over those of previous eras, and on the certainty that the mistakes made before have not been repeated. Time reveals whether those attitudes and positions were justified. For Soderbergh, the director of the series, this idea was top of mind, and he stated as much in an interview published in the August 1, 2014 New York Times:  

There are so many treatments on the show that make you gasp because they’re so wrong…It just makes you wonder what treatments we’re all taking at face value that 10 or 15 years from now we’re going to be told, ‘Well, that didn’t work, and in fact that makes it worse.’  

Early twenty-first-century medical care has benefited from advances in molecular biology, medical devices, surgical procedures, data analytics, and epidemiological methods among others. People only participate in experimental protocols with their informed consent, and health care workforces are highly diverse. Impressive indeed, but none that in any way dwarf some of the advances shown during the series, and many that make twenty-first-century medical care possible. And, while The Knick shows how patients were often victims of bad science, bad technique, unproven technology, and malfeasance, the current era of health care is rife with risks for its own harms. Based on a complex analysis from several sources, the U.S. Institute of Medicine estimated in 1999 that between 44,000 and 98,000 people die from preventable medical errors each year in the US (To Err is Human). In 2016, researchers from The Johns Hopkins University reported in the May 3, 2016 issue of The BMJ (The British Medical Journal), that at the time The Knick was running in 2014–2015, medical errors were the third leading cause of death in the U.S. While the the accuracy of these estimates could be challenged, we can take from them with some amount of certainty that medical error exists today to a significant degree.  

The Knick pushes us to consider and to beware of what we may see resulting from modern-day biomedical and technological advances as time passes. To the medical drama and personal drama of most television medical serious, The Knick adds the drama of time. 

—————————- 

The Knick
Steven Soderberg, director 
Cinemax 
Twenty episodes, 2014-2015 
Running time: 42–57 minute episodes 

Awards
Peabody Award 
Six Primetime Emmys 
Three Critics Choice Television awards 

The Knick began streaming on HBO Max on February 20, 2021