Disclaimer: I wrote this review about ten days ago. If reading about quarantine or infectious diseases is going to make you stressed right now, maybe skip it.
Oh, man, talk about a curate’s egg of a book. The Dark Circle, by Linda Grant, is my pick for the Women’s Press square of the Indie Challenge. It’s about 18-year-old twins Lenny and Miriam, who are diagnosed with TB shortly after WWII and sent from their home in London’s East End to an NHS-run sanatorium in Kent. The sanatorium used to be private, but following the establishment of universal health care it has been opened up to all patients. Lenny and Miriam are the first true “commoners” that the sanatorium has accepted, and the culture clash between themselves and the long-term patients forms a theme that runs throughout the novel. In short, this book should be extremely up my street. It’s got interesting class issues, fascinating medical history, a love letter to the NHS. That’s pretty much all I ever want from a book. And yet. And yet.
I’ll start with the things I loved about the book, because there were plenty. Overall, the novel was fast-paced, and it didn’t suffer from that feeling of being bloated that so many contemporary novels do – it comes in at around 300 pages, and all of them feel necessary. I also enjoyed the look at London’s East End in the late 40s. That’s not a place or time that I know very much about, and I thought it was drawn in a compelling and vivid way. Sadly, we don’t spend much time there (most of the action was in the sanatorium), but the parts of the novel that do occur there are fascinating. The stifling stillness and loneliness of the sanatorium are also well-drawn – it really did feel suffocating to read about – and the contrast between the high-energy, high-volume East End markets at the start of the novel and the slow silence of the sanatorium is disorientating. It’s easy to believe that Lenny and Miriam would have found it accordingly harder than other patients to adjust.
The melting pot of people from different classes and backgrounds was also fascinating. I’ve always thought of WWII as the place where class boundaries started changing in British society, partly because the war allowed a lot of people to achieve a degree of social mobility, and partly because it seems that people simply mixed more with people from other backgrounds in WWII than in WWI. I hadn’t really considered the fact that the NHS also allowed people from drastically different upbringings to work together and receive care from one another. This book has people ranging from landed gentry to petty criminals stuck in isolation together, and developing friendships across those boundaries. In real life, it is entirely possible to form a close friendship with someone who is extremely different to you, and I thought that was convincing in this novel. Most of the characters are three-dimensional, with the possible exception of a merchant seaman who seems almost cartoonishly American. Although I didn’t find any of the friendships particularly moving, I did find them believeable, and I appreciated that.
Now onto some of the downsides. I found the writing in this book very odd in places. I wondered initially if this were a debut novel, because it suffers from a surfeit of peculiar similies and regular shifts in style – it reads like someone who has been experimenting with the various techniques they’ve just learnt in their creative writing MA, but hasn’t quite got fluency with them yet. At one point, for instance, a character thinks of another character: “her breasts pushed out in front of her like off-white cats curled up on a sofa”. That… doesn’t mean anything? Breasts don’t resemble cats in either appearance or function. What am I meant to take from this sentence? It comes in the context of a woman describing Miriam to herself, thinking about her energy and vigour and cheap glamour – sleepy cat boobs do not fit in this picture. There was quite a lot of this sort of thing, and it always took me out of the story.
There is also a tendency in historical fiction to blame people for not knowing things they would know fifty or a hundred or a thousand years later. The doctors in this book are viewed as monstrous for a) using admittedly barbaric TB treatments that were current at the time*, and b) not giving out streptomycin straight away (as, indeed, doctors continue to be portrayed as villains for following proper regulatory processes when treatments are developed). The isolation of children receiving TB treatment is also raised as a concern. I can completely understand the characters feeling that way, but I felt that the overall narrative kind of agreed with the characters – we don’t really get any insight into the healthcare professionals or their reasoning, except for one short conversation. The thing is, streptomycin is a horrible drug with awful side effects – it took a while to get onto formularies because staff did not want to make people sicker – and TB is a contagious illness that puts patients’ families and loved ones at great risk. We manage isolation differently now, but we still use vigorous infection control techniques.
Used carelessly, streptomycin can cause nephrotoxicity and ultimately renal failure – potentially killing recipients more quickly than TB – not to mention anaphylaxis in a pre-epipen world, ototoxicity leading to deafness, etc etc. Writing a novel in 2018 that criticises doctors in 1948 for not prescribing streptomycin for TB, when the first randomised controlled trial proving efficacy didn’t even finish until 1948, is properly nonsensical**. On the same topic, the Platt Report (showing the devastating effects of isolating young children away from their families) didn’t come out until 1959, and even the work by John Bowlby that prompted the Platt Report wasn’t published until 1951***. Look. I could do this all day. We can definitely recognise the ways in which healthcare professionals have caused harm throughout the ages without going “hey, why didn’t you use a 21st century understanding of healthcare to treat this person in 1948?” The novel does eventually come around to a more nuanced picture, but it takes so long to do so that it seems to come out of nowhere.
All that said, I am still glad I read this novel. The subject matter was so interesting, and it made me freshly grateful for my BCG scar. And National Insurance contributions. And never having had a pneumothorax (spontaneous or induced). The Dark Circle was published in 2018, which was the 70th anniversary of the NHS, and I think it did a good job of celebrating the achievements of universal healthcare while also critiquing some of the ways in which it has reinforced inequality over the years. During my career in nursing (including as a healthcare assistant and student nurse), I’ve only ever looked after three people with TB, and none of them caught it in the UK. I had a colleague with latent TB, and thanks to prompt treatment, she has never developed active disease. If I’d trained and worked in the same hospitals 50 years ago, those numbers would have been unfathomably higher. There’s progress to be thankful for, even if there’s still plenty of work to do.
*I would definitely be confused and distressed if I had a disease affecting my lungs and I was told that the treatment was to collapse one of my lungs. But, look, inducing a pneumothorax was the first semi-successful treatment of TB. Let’s just all be glad we have drugs for that now, rather than blaming historical physicians? At least they’d stopped treating it with bloodletting by then.
**As you may be able to tell, the whole drug approval and regulation process is a bit of a hobby horse of mine. So often, the answer to “why isn’t this wonder drug available on the NHS yet when US doctors are giving it out like sweets?” is “because we want to make sure it helps more people than it hurts” and “seriously, haven’t you heard of the opioid crisis? Or, you know, thalidomide?”
***I am not arguing that it was good that we completely isolated children for infectious diseases pre-Platt. I am arguing that it was understandable and that it came from a good place.
I love reading your reviews that share the knowledge you’ve gained in your education and career; the books are always more fascinating that way. I think people forget that that the older they get, the more they’re going to realize they’ve had things done to them by medical specialists that were perfectly normal at the time and are no longer done. Like metal fillings. Unless a doctor is practicing on someone without their consent, or making decisions they know to be unethical, we should all try to remember than human beings are works in progress.
I’m reassured by that – I’m very passionate about healthcare and about medical history, but sometimes I feel like I’m just banging on about it! This was a time of really rapid change in healthcare – especially in the UK because of the NHS, but all over – and it was difficult for doctors to keep up with the pace of change, but most of them really were just normal people who cared about their patients. But I guess they don’t make very good stories.
There’s a blogger named Amal who is a lawyer, and like you she’s busy and doesn’t blog nearly as much as some other folks, but I’ve been following her (and you) for years because you both bring your special interests to your reading and reviewing.
I love Amal’s blog!
Pity it does all the blaming thing – that always annoys me too. All I want fictional doctors to do is their best as far as they knew it at the time, even if that involves things that make us shudder now. Who knows what we do today that people of the future will sneer at? My first job was in a hospital that had once been a TB hospital – by my time, it had become a geriatric hospital – and it had open verandahs where the poor patients were apparently stuck out all day long bundled up in blankets to get ‘fresh air’. I have no idea if it worked but blimey, those verandahs were freezing – I’m not sure Scotland is the ideal place for lying outdoors in winter!
There were people lying outside in this book too – one of the patients got snowed on in her sleep! I don’t think that was ever a particularly effective treatment, though people taken from very smoggy cities probably got bought a bit more time by being in a less polluted environment.
I agree – there will be things that we do now that people of the future will be horrified by. Even in my relatively short career, I’ve given treatments that are now no longer prescribed or recommended, and I’m sure there will be plenty more abandoned by the time I hang up my stethoscope!
I really appreciate your critique of the way the health care is portrayed here! It seems like books that portray doctors in such a one-sided way could contribute to some of the problems we have with people not trusting doctors now.
I think in the UK we are pretty lucky and people mostly do trust doctors, but in a more general sense I think that the portrayal of doctors as being in a “conspiracy” with various unsavoury elements (which often happens in media) causes problems – e.g. with vaccination attempts or public health initiaves globally.