I really admire Atul Gawande for his pointed and precise medical journalism. It isn’t often that a doctor can craft such stirring accounts of health care’s nuances; Oliver Sacks, too, has argued [Radiolab] for a more literary approach to medical writing, in order to expose the many emotional and psychological layers of an ailment or experience. Together, their writings range from “micro-tales” to expansive, almost sociological, essays. Gawande’s most recent piece for The New Yorker is a great example. “Slow Ideas” tells the story of how some innovations—like antiseptic, for instance—don’t catch on right away. They trickle through institutional cracks long after their inception, thus proving that medical fixes aren’t always fueled by logic alone.
Early in the piece, Gawande writes about a nurse in a decrepit hospital who neglects to swaddle mother and child. The mistake has the potential to trigger hypothermia in the baby hours after the nurse has completed her portion of the task. This anecdote demonstrates a severe lack of foresight in the educated but uninformed nurse; for her and others, preventing hypothermia “demands painstaking effort without immediate reward”:
Everything about the life the nurse leads—the hours she puts in, the circumstances she endures, the satisfaction she takes in her abilities—shows that she cares. But hypothermia, like the germs that [Joseph] Lister wanted surgeons to battle, is invisible to her. We picture a blue child, suffering right before our eyes. That is not what hypothermia looks like. It is a child who is just a few degrees too cold, too sluggish, too slow to feed. It will be some time before the baby begins to lose weight, stops making urine, develops pneumonia or a bloodstream infection. Long before that happens—usually the morning after the delivery, perhaps the same night—the mother will have hobbled to an auto-rickshaw, propped herself beside her husband, held her new baby tight, and ridden the rutted roads home.
This story reminded me of a passage in the memoir Reading Lolita in Tehran, which I’m reading right now. The author explains the “fragile unreality” (Nabokov’s words) of her life—as well as her students’—via the metaphor of a blind Iranian film censor:
After 1994, this censor became the head of the new television channel. There, he perfected his methods and demanded that the scriptwriters give him their scripts on audiotape; they were forbidden to make them attractive or dramatize them in any way. He then made his judgments about the scripts based on the tapes. More interesting, however, is the fact that his successor, who was not blind—not physically, that is—nonetheless followed the same system.
Our world under the mullah’s rule was shaped by the colorless lenses of the blind censor. Not just our reality but also our fiction had taken on this curious coloration in a world where the censor was the poet’s rival in rearranging and reshaping reality, where we simultaneously invented ourselves and were figments of someone else’s imagination.
The nurse and the film censor both have reasonably well-developed methods and approach their work with intelligence. The nurse is highly knowledgeable despite the extreme poverty, and the censor has become so entrenched in his carefully honed system that eventually his successor follows it, too. But some basic concepts—and alternate worlds—are invisible to them. Processes and ways of seeing lay beyond their reach. It turns out that, as Gawande notes, revolutionary efforts often require deeper changes than most people anticipate. The problem is that few of us are prepared to go to such great lengths:
In the era of the iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions to the major difficulties of the world—hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability.
Luckily, we live in a world where a small subset of the population realizes the value in working directly with people—by appealing to their emotions and by moving their mental horizons—in an effort to spread innovation. Gawande recalls asking a pharmaceutical representative how he persuades doctors to use new medicines. “‘Evidence is not remotely enough,’ he said, ‘however strong a case you may have.'” Evidence is not enough.