American Unreason

Many TV​ shows are set in hospitals, but fewer novels, at least ones that take place outside the psychiatric ward. Hospitals make for good drama: the path to diagnosis is a mystery plot with inherent narrative tension; the stakes are life and death. The best physician-novelists – Arthur Conan Doyle, Michael Crichton (who was also the creator of the show ER) – deploy technical language and scientific reasoning to produce an effect of dazzling competence. For the lay reader, the presence of a scientific authority figure is soothing, the revelation of biological cause satisfying and incontrovertible. Consider the pivotal moment in A Study in Scarlet, when Watson places his hands on the chest of the murder suspect and discerns ‘an extraordinary throbbing and commotion’. ‘Why,’ Watson quickly deduces, ‘you have an aortic aneurism!’ ‘That’s what they call it,’ replies Jefferson Hope, who has just murdered two people because he has been told he has nothing to lose.

That’s what they call it – the patient submits not only to the authority of a doctor but to his unassailable medical terminology. Jefferson Hope’s condition seems similar to the one that threatens the unnamed narrator of Garth Greenwell’s Small Rain, although in this novel it takes the doctors a while to figure out what’s wrong, and diagnosis doesn’t bring resolution. Instead, the hospital is a place of bureaucracy and confusion, where you might be kept alive but left in debt, the course of treatment is decided by unseen administrators, and a few acts of negligence can kill you.

Small Rain begins with pain. It’s the summer of 2020, in Iowa City, and one Saturday the narrator suddenly doubles over in agony. ‘The pain defied description,’ he says. ‘It was like someone had plunged a hand into my gut and grabbed hold and yanked, trying to turn me inside out and failing and trying again. Like that, while somebody else kneed me in the groin.’ He is dazed and incapacitated. For the next few days he does nothing to address the pain. His partner, L., who is Spanish and ‘has a European sense of what it means to be ill’, urges him to see a doctor, but he refuses. The first summer of the Covid pandemic is not a time to go to the emergency room. And the narrator is wary of the American health system, where ‘doctors waste your money and your time, and send you home the same or sicker.’

He waits. A fever sets in. He is lucky to be covered under L.’s health insurance, which is subsidised by the university where L. teaches. Their monthly payments are twice as expensive because they aren’t married, but not marrying is a small protest against the ordering forces of society. The narrator finally goes to a university clinic. The nurse there sends him to the emergency room. Sick and injured people are sitting on the floor, ‘like an airport in bad weather’. As he waits for hours to be seen, he exchanges texts with L. ‘He couldn’t believe I hadn’t seen a doctor yet, how could the system be so dysfunctional, why did we put up with it.’ The American narrator, and perhaps the American reader, has given up asking such questions. ‘I remembered my outrage, in middle school or high school, when Congress passed a resolution declaring global warming a myth,’ he thinks, while he waits in pain.

What assholes, I thought, these men who were like children, thinking wishing makes it so. But it had become impossible to ignore, American unreason, it had come to seem less aberrant, less a thing of the margins than at the heart of what we were, it had corroded the idealism that had always also been a part of my sense of my country, I mean my sense of myself; corroded it not just for me but for nearly everyone I knew, for nearly everyone altogether, it seemed, for that weird intellectual weather we had taken to calling the Discourse, the amorphous impersonal sense of things that came from scrolling through social media, from watching fifteen-second video clips on YouTube. It was like we had outsourced consciousness, turned inwardness inside out, we thought now in other peoples’ memes. It made me despair for my country, not just my country, for the endeavour of humanness – something it had become impossible to think of unironically, an idea that could only be mocked.

‘American unreason’ is the atmosphere that pervades this novel, which is in part about how a near-death experience puts one in confrontation with the American myths of independence and agency. Greenwell’s clauses pile up like cars hitting a traffic jam on the highway, building a pressure that in certain passages generates a thrilling anxiety and in others stagnates into the boredom of a long wait. It’s a book about the era when Americans put out lawn signs that read ‘In this house we believe science is real,’ and when they also began to understand that what one believed in one’s house no longer had much bearing on a society increasingly ordered by ‘other peoples’ memes’.

Once he is finally seen in hospital, the narrator finds some relief in submitting to an ordering force. Between long waits, his name is occasionally called. His vitals are taken and he is given a bracelet with a barcode on it. His blood is drawn. He has a CT scan. It’s only when the results of the scan arrive that urgency sets in. No longer allowed to walk, the narrator is put in a wheelchair and rushed through the halls of the hospital. A room is found for him. ‘A lot of people want to talk to you,’ a nurse practitioner tells him. He is told what’s wrong, ‘but the words didn’t mean anything. I could only understand one of them, aortic; there sprang into my mind a scrap of a poem, the blown aorta pelting out blood, which I couldn’t place and was of no help at all.’ (In his acknowledgments Greenwell names the poem, Geoffrey Hill’s ‘The Triumph of Love’.) I was reminded of Ben Lerner’s 10:04, another first-person novel about a Gen X American poet living with the knowledge that his aorta might rupture – ‘an event I visualised’, Lerner writes, ‘however incorrectly, as a whipping hose spraying blood into my blood’.

A doctor finally explains the diagnosis, a tear in the inner wall of the aorta called an infrarenal aortic dissection. ‘I asked her to repeat it before she went on, then I repeated it myself. Right, she said.’ Greenwell describes each aspect of the treatment that follows in exquisite detail. It is both extremely advanced and utterly rudimentary: the ICU is less about curing than stabilising, bringing all the numbers into normal range. The narrator is attached to IVs, flooded with antibiotics and blood thinners, and inserted with an arterial line after his veins give out. He must bathe with antibacterial wipes that smell of chemicals. ‘Everything around me was a mystery – which is always true,’ he says. ‘I don’t know how anything works: my computer or a light switch or an airplane or a car.’ He ponders the uselessness of the things he does know – ‘iambic pentameter, functional harmony’. Hooked up to machines, he clings to every instance of the human: the nurse wearing pins that indicate she’s queer (‘everyone else had seemed so relentlessly heterosexual’); the orderly who gently strokes his ankle. His favourite nurse is named Alivia, the Spanish word for ‘relief’. He is at once special – ‘an ER doctor’s dream, you come in thinking you have something simple but it turns out to be much more interesting,’ a nurse tells him – and cursed. His condition has a ten-year survival rate of 10 per cent. He is reprimanded for not having gone to the doctor immediately, and told he is lucky to be alive.

Greenwell’s previous books, the novella Mitko and the novels What Belongs to You and Cleanness, had a different tenor. They focused on expatriate life in Bulgaria and the intense sexual pursuits of their first-person narrators. While his books share biographical continuity – the narrators seem to be the same teacher from Kentucky with a homophobic father – their specific plots hardly intermingle. Mitko, the troubled gay hustler at the centre of Mitko and What Belongs to You, is not among the people from the narrator’s past recalled during his illness. The first two novels are in part about the non-belonging of the foreigner, for whom the stigmas and social hierarchies of the country he lives in don’t apply. Always present in Bulgaria is the knowledge that the narrator can simply leave, and that he eventually will. The sexual relationships in those books are furtive, charged with risk and sometimes violence, but contain defiance and possibility. I read them with an envy for the freedom of male sexual adventure and found it hard to reconcile the narrator of What Belongs to You, who has sex in a public toilet, with the narrator of Small Rain, who is now either monogamous or just discreet. Some step seems to be missing from the raw exposure of the earlier books to the uxorious descriptions of L.’s taste in interior design, as if the emergency has landed the narrator not only in hospital but within the domestic contours of a David Sedaris essay. In the new novel, one of the only references to that earlier life is the mention of a syphilis infection contracted in Eastern Europe; the doctors investigate this as one possible cause of the aortic dissection, before ruling it out.

Even before his health crisis, the narrator had accepted that one cannot live without enduring commitments. As he undergoes treatment, he recounts the history of his recent domestication: moving back from Bulgaria, quickly falling in love, buying and renovating a house with L., putting down roots in the Upper Midwest. ‘I had never imagined I might be responsible to someone in the way I was to L.,’ he says. ‘I had never imagined anything but a solitary life, maybe I still couldn’t imagine it.’ There’s a way in which the nimbleness of an itinerant life leaves one with a false sense of safety – if there’s nothing to destroy there’s nothing to lose – and now, as illness strikes, the narrator understands the strength of his ties, that he now exists in the world with its rules and not in the safety of its margins. There is no escaping his dependence on others nor the ordering of society, the cruelty of a country that punishes the sick and vulnerable.

Published in September, just before the US presidential election, Small Rain reads as a document of the interregnum between the two Trump administrations. Greenwell’s narrator isn’t sure what the upheavals of 2020 portend. One reason the hospital is full is that Iowa had been aggressive about ending its lockdown. The return of students to the university, ‘to everyone’s dismay’, caused a surge in Covid infections. When the narrator turns on the TV from his hospital bed, images of ‘armoured men with batons striking figures huddled on the ground’ fill him with ‘grief and rage’. Describing Breonna Taylor as ‘a sleeping woman murdered in her bed’ by police officers in his hometown of Louisville, he feels ‘an impossible dismay’. The protest he had attended in his college town that summer ‘just felt like theatre’. All the emotion of those months, whether about the protests for Black lives or the controversies over anti-Covid measures, seems ineffectual. ‘What was it for, I wondered. I watched the news, I sent money to bail funds, I brooded on my uselessness.’

Small Rain also contains the passages mourning ecological destruction and the excesses of consumerism that have seemed almost compulsory in recent self-reflective fiction. The art on the walls of the public areas of the ICU shows a Midwestern prairie in bloom, ‘though there wasn’t a prairie any more, not really. It was the most devastated ecosystem in the world.’ The narrator meditates on a bag of crisps, a ‘chichi brand made with avocado oil’, which contains ‘histories of conquest and colonisation, industrial agriculture and ecological devastation, and along the whole chain the devastation of human bodies, from labourers in the fields to fat Americans shopping organic markets’. L. is horrified by the ultra-processed food at the hospital; the narrator, who was raised on it, less so – ‘if you taste it as a child, you crave it your whole life.’

Reading these passages before the election, and again after it, I was surprised by how upset they made me. Not at Greenwell, who was only putting his thoughts in writing. But the pining for an idealised European-style healthcare or for intact ecosystems, the marvelling at the labour involved in the production of a snack, now only reminded me of the recent electoral failure of the politics of concern. Other people were acting without this futile performance, and they made the world around us. In seeing the history of empire in a crisp, Greenwell conveys only the uselessness of his knowledge – the literary equivalent of a land acknowledgment. This fretting may come to be seen as an artefact of its time, as marginal as the medium delivering it. Small Rain is, among other things, a lament. The narrator sees signs of the rise of right-wing politics in the gun rack of the contractor renovating his house and in his estranged father’s move to Florida – ‘his Facebook was full of posts about the president and rigged elections; if he were younger and well, if he had more courage, he would have been out marching with guns, another terrified old man desperate to feel strong.’

Greenwell’s narrator tries to stop thinking about the systems over which he has no control and to focus on his relationship, his home, poetry. The hospital stay redirects the normal paths of his attention away from his phone. He is too sick to read, but one day, while staring out of the window, he sees a sparrow and thinks of a poem by George Oppen. L. brings him the book in hospital. ‘The poem has been about the one and the many, the individual and so also about the mind that can distinguish the individual,’ the narrator says. ‘Maybe that’s why I wanted the poem, because it understood that, it explained to me why the particularising attention of the doctors and nurses, all the precise data they collected from my specific body, had nothing to do with me, really, left the crucial me unseen, untouched.’ He reflects that ‘the disciplined attention of art is a moral discipline, even when the content of that morality isn’t obvious.’ The suggestion is that we might control our attention, if nothing else, but the narrator finds that there are limits even to the autonomy of the mind.

The most propulsive parts of Small Rain are the descriptions of medical treatments. In one passage the narrator describes the panic of undergoing a positron emission tomography scan while desperately needing to urinate, a scene that has Mission Impossible levels of tension. Trapped in a tube, his veins having been injected with radioactive tracer, he tries to calm himself by reciting scraps of poetry. It doesn’t work. In the end he can only repeat two words, a mantra: ‘naked rock’. The test results are inconclusive. But the narrator’s condition has finally stabilised, and the tear has healed sufficiently that he is no longer in excruciating pain or in immediate danger of dying. He is sent home with prescriptions for blood pressure medication, Oxycontin and a laxative. ‘Everything was unresolved, why this had happened and what happened next: they had never even found an infection.’ Under the circumstances it’s difficult to wrap up the novel. ‘I can’t believe they are letting me go,’ the narrator says as he is discharged, left to climb down the stairs ‘one by one, like an old man’. It’s the opposite of a show like ER or House, where the application of medical knowledge explains the world. The doctors and nurses saved the narrator but can offer no answers. The book concludes with a meditation on the pleasures of watching a dog play – an unsatisfying ending, but perhaps that’s the point.