Cancer Ward

[I'm back! I know, I know; my choice of beach reading is unorthodox. But this is the first novel I finished in Hawaii.]

In a hilarious piece of reverse synchronicity, I happened to attend a conference on "Patients as Leaders in Health Care" while I was in the middle of reading Alexandr Solzhenitsyn's Cancer Ward. At the conference, a smattering of Oregon health care professionals discussed how to involve patients and families in the decision-making processes at their medical groups and health plans; how to collaborate with patients and families to make the experience of treatment the best it can be; how to coordinate care so that patients and families take an active role in determining the course of treatment, making informed decisions and being a partner in their own care. What with national health care reform and state-level changes in the field, this is a pretty hot topic right now, and several early studies have tied a coordinated care model to improvements in patient morale, greater medical staff satisfaction, and significant monetary savings overall. The conference was focused on envisioning a future better than the present; but if the attendees had been interested in getting a clear picture of the absolute, perfect opposite of the care model they're trying to implement in Oregon, they would not have to look much further than Solzhenitsyn's semi-autobiographical 1967 portrait of life in an outlying Soviet cancer ward.

Medical transparency? How about doctors who lie sunnily to all their patients, telling them they have "no cancer whatsoever" when in fact their case is terminal, and insisting that there be no talk of death or illness on the ward, but only enforced joy at every new turn in the treatment. Patient involvement? Let's try regulations forbidding doctors to explain to patients the reasons behind, and even the side effects of, experimental treatments that will leave the patients addled or impotent. A holistic view of the life/death cycle? Here we've got a hospital that discharges patients on the brink of death, telling them they're cured so that they'll go die in a train station or public park, freeing up beds in the ward and improving the hospital's statistics, since the patient did not die on their premises. I couldn't help but chuckle when, at the conference, I was able to think of perfect Solzhentisyn-derived counter-examples to almost every point raised.

And yet, despite my horror at the way the Soviet ward is run, there is a bizarre kind of logic about its structure. Those running it aren't cruel or uncaring; they're legitimately operating under the belief that it's better for most people to remain in near-total ignorance most of the time. Even many patients agree with this; the following passage is told from the point of view of Pavel Nikolayevich Rusanov, a government official with a throat tumor:

They had hung a banner across the wide staircase landing. [...] The message was written in the usual way in white letters on a long piece of red cotton: "Patients, do not discuss each other's illnesses!"
        Of course with such a grand piece of calico hanging in such a prominent spot, some slogan to celebrate the October Revolution or First of May anniversaries would have been more suitable. But this was an important appeal for the people who lived here. Pavel Nikolaevich had mentioned the matter several times, to stop patients upsetting himself and each other.
        (Generally speaking, it would have been more statesmanlike, more correct, not to keep the tumor patients all in one place, but to spread them out among ordinary hospitals. They wouldn't frighten one another then and one would be able to hide the truth from them, which would be much more humane.)

Regular readers will know that I have a fascination with stories about life in quarantine or on closed wards: Cancer Ward follows on the footsteps, most recently, of Saramago's Blindness and Mann's The Magic Mountain in this genre. Unlike those somewhat fantastical, metaphorical novels, however, Cancer Ward strikes me as a work of extreme realism. Sure, it's possible to extrapolate larger truths about the Soviet state from the way the cancer ward is run, but those extrapolations are right on the surface of the text, whose strength comes rather from the gritty, day-to-day portrait of life and death in this environment, and the ways in which the different characters react to that grim reality.

Solzhenitsyn's style combines elements I consider typical of Communist literature (accessible, workhorse prose; the depiction of characters as "types"; a portrait of an entire community rather than one unique individual) with harsh critiques of the Soviet mindset and other, more individualistic literary elements—the community depicted, for example, is far from unified. Particularly fascinating was observing the characters' different reactions to the shifting winds of governmental favor. Set in the Spring of 1955, two years after Stalin's death, the novel encompasses the beginning of the "thaw" in Soviet Stalinism, after which many political prisoners who had been sent into exile or imprisoned in labor camps were granted amnesty. Signs of this upheaval reach the patients and doctors in Solzhenitsyn's outlying ward: there is a complete purge of cabinet and prime minister, with all the officials privileged under Stalin swept aside, and the two-year anniversary of Stalin's death is hardly commemorated at all in the paper. Rusanov, who has a real belief in the Stalinist system and who has also benefited unfairly by it, feels shocked and betrayed at these developments. He remembers his devotion to Stalin, and is terrified that the men and women he helped denounce will return to find him. Oleg Kostoglotov, on the other hand, a former political prisoner who has been sentenced to "exile in perpetuity" (based on the author's own history), allows himself a cautious ray of hope upon learning of the governmental changes, and remembers the reaction in his camp to the news of Stalin's death:

People were moving along the bunks, sitting down on them and saying, "Hey, kids, it looks like the old cannibal has kicked the bucket..."—"What did you say?"—"I'll never believe it!"—About time!" and a chorus of laughter. Bring out your guitars, strum your balalaikas! They didn't open the barracks blocks for twenty-four hours, but the next morning (it was still frosty in Siberia) the whole camp was formed up in ranks on parade. The major, both captains and the lieutenants—everyone was there. The major, somber with grief, began to announce, "It is with deep sorrow...that I must tell you...that yesterday in Moscow..."
        And they all started to grin, they were all but openly crowing in triumph, those coarse, sharp-boned, swarthy prisoners' mugs. The major saw them as they started to smile. Beside himself, he ordered, "Caps off!"
        Hundreds of men hesitated on the verge of obeying. To refuse to take them off was still of out of the question, but to take them off was too painfully ignominious. One man showed them the way—the camp joker, the popular humorist. He tore off his cap—it was a Stalinka made of artificial fur—and hurled it up into the air. He had carried out the order!
        Hundreds of prisoners saw him. They too threw their caps in the air!
        The major choked.
        And now after all this Kostoglotov was finding out that old men had shed tears, young girls had wept, and the whole world had seemed orphaned...

It is this collision of perceptions and value systems in a changing time that makes Cancer Ward such a compelling read. Later still, we get the perspective of a man who didn't, like Rusanov, believe in the system, but still played the game in order to avoid Kostoglotov's fate. Shulubin, a former academic, has accepted ever less prestigious, safer jobs, has confessed and recanted whenever, asked, and quietly burned books when ordered by the government. He seems literally eaten from the inside by bilious self-hatred at never having spoken up against his the abuses of his government. So too, there is the younger generation, accepting or questioning the world into which they were born without the baggage or knowledge of their elders. Collectively, they make up a portrait of a society in flux—one that I found hard to put down, despite (and because of) all the cruelties and frustrations it includes, and because of the fascinating questions it raises about the nature of history, and how history can be different for each person who lives through its twistings and turnings.

(Cancer Ward was my third book down in my personal TBR Challenge.)