‘This Living and Immortal Thing’ by Austin Duffy (Granta Books, 2016).
This living and immortal thing refers to the ability of cancer cells to outlive everyone. Some of these cells, such as the now famous HeLa cell line (named after Henrietta Lacks, a patient) live on forever in lab studies. The idea is central to this new work, which appears at a fascinating and productive time for physician authors. The past few months have yielded books on ageing, dying, a doctor dying, psychosomatic illness, and experiences of being a surgeon. There is no doubt that the medical perspective has offered a unique insight to each of these factual accounts. But it is refreshing to turn to a work of fiction written by a doctor, which offers a medical skew on an everyman story.
The author Austin Duffy is a practising oncologist, who trained in Ireland but works in the United States. His unnamed character in this book, fondly referred to as “postdoc” by a friend, is clearly a version of himself – an Irish oncologist who has gone to New York to develop his career. Or so it seems, for like many of us (Irish doctors, as I am) other reasons soon become apparent for the move.
He works in a cancer research centre attached to a large teaching hospital in Manhattan, but has somehow lost his fondness for clinical medicine and turned to lab work. His exodus from the wards seem to have been triggered by a devastating outcome for a patient of his that occurred just moments after she had left his clinic. As we grow to understand him, we realise that the controlled, protocolised world of research suits his current passive state and offers him a comfortable, if unchallenging, haven – ‘you bloody well have the personality for it’ chides his absent wife. She remains in Ireland and we gradually learn the complex reasons behind this.
He seems emotionally and professionally at sea when we meet him, and one wonders what can shake him from his coma. The ensuing story revolves around his relationships with two other characters: a Russian girl (Marya) who volunteers as an interpreter for cancer patients, and cancer itself. A chance meeting and a physical attraction trigger his growing fascination with Marya, who seems somewhat troubled. She likes asking him about his cancer work, but resists his clumsy attempts at dating and closeness. She moves in similar circles, attending grand rounds and lectures and even knowing some of his esteemed colleagues, though she herself is not a medic. While distance increases between him and his wife, he forms a strong human connection to Marya. Circumstances intervene however, and he subsequently finds this situation reverses.
The quiet implosion of his relationship with this wife, told in retrospect, provokes little emotion in the reader, as it seems clear they were poorly matched. But the description of how unyielding attempts at reproduction became the key issue is honest: ‘Our efforts became a parody of sex until that stopped also’. A miscarriage leads to her sombre declaration ‘we are incompatible’. When she announces that she will not be going to America with him, his response is simply silence, followed by what he thinks is relief.
Duffy’s novel is at first glance pure fiction about the intricacies of human relationships. But it has a side line of being quite educational about cancer, and he uses this to ensure we achieve a deeper sense of what subsequent events mean. The story is intimately related to the trials of the cancer cells in his lab studies. Complex terminology pervades through the story and whilst it struck me that this could be laziness, it echoes our constant struggle to make medical language accessible.
The balance between fiction and imparting scientific knowledge makes this book unique. It is peppered with scientific asides – footnotes explaining diverse topics such as telomerase, paracentesis, BRCA and hallmarks of cancer. I realised that these have been carefully placed for maximum effect. Duffy is skilled at deception and allows the reader to misstep due to his pleasant digressions so that plot twists remain unexpected (indeed, the narrator is described by his teacher as a “fan of distraction”).
The book is shot through with wry humour, such as the description of certain patients who sought preferential outcomes for their cancer as they ‘seemed to be under the impression that my job came with additional discretionary powers’. Duffy doesn’t hold back on socio-cultural commentary when it comes to the U.S. The narrator laments the overuse of exclamation marks in emails, and the incisive ‘they don’t have Down’s Syndrome in America’ – which is a particularly personal issue for him as he has a brother with the condition. It also extends to commentary on aspects of medical politics that will be familiar to most of us: the surgeon who ‘laughs a lot but is apparently not safe’ with patient care, the self-obsessed research director, the caring and empathetic older physician. Some of these references cut quite close to the bone and allow for identification since Ireland is a small place, such as the ‘well-known orthopaedic surgeon in Dublin with a small celebrity practice’.
He also draws on his medical experiences to enrich the narrative: the patient being moved to a corner room signalling the shift to palliation, his over-eager efforts to convince his colleagues that leaving clinical medicine was the right thing to do, and his reflection that in medicine you only have an illusory or – at best – superficial control over things. This last statement fascinates me, as it shows the inherent contradiction in medicine that there are many shades of grey – as teachers often told me that ‘Medicine is an art, not a science’.
Duffy is an accomplished writer and has managed to make a fascinating and complex book seem deceptively straightforward. In this, his work is likely to have flown beneath the radar somewhat. It took a second read (with the added knowledge of the ending) before I discovered the deeper meaning behind several passages.
Duffy’s story is ‘a reminder that you are not here forever, or even for all that long’. This contrasts with the strange quirk of science suggested by the title – that part of us can live on as an immortal line of cancer cells. For all who hold an interest in medical humanities it represents a touching, well thought out narrative on human relationships (including that of the doctor-patient) and the power of cancer to do both good and bad. The beautiful writing is often dotted with medical imagery: ‘an expanse of stars, tiny and remote and light years away, against the normal blackness of her lungs,’ and ‘the hours were as thick as lymph’. These remind us that as doctors we have a unique insight into human suffering and a position of privilege that we should perhaps appreciate a little more often.
Reviewed by Dr Shane O’Hanlon, a consultant in elderly care medicine at the Royal Berkshire NHS Foundation Trust. He completed most of his training in Ireland before subspecialising in geriatric oncology. He now helps to assess the very individual needs of older people with cancer. He previously led the humanities in medicine module at the Graduate Entry Medical School, University of Limerick.
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