Book review

Is it just the president’s son or all of us who are trapped between the living and the dead?

George Saunders’s spectacular new novel, part-fantasy, part-philosophy, combines an invented otherworldly narrative with real-life reportage.

In his fine monograph Angels and Ages, Adam Gopnik built a thesis about liberal thought and expression by drawing on the connections between Charles Darwin and Abraham Lincoln, two epoch-defining figures who were born a few hours (and an ocean) apart on February 12, 1809. Among other things that linked them, each man lost a favourite child: Darwin’s daughter Annie died aged 10 of tuberculosis; a decade later, Lincoln’s 11-year-old son Willie succumbed to a form of typhoid.

It is sometimes thought, Gopnik says, that because child deaths were so much more common in the 19th century, parents of the time “felt them less, or differently, than we might think – or made less of a fetish of them”. However, he makes the opposite proposition. “If anything, their grief was deeper, because their shock was less. There was no surprise to buffer it, no sense of a million-to-one shot to place it in the realm of things that never happen. It was […] the one thing you had always actively dreaded.” And he points to the many reports of Lincoln’s immeasurable sorrow, at a time when one would think the President had enough to distract his mind (the Civil War was underway, he was the target of much nationwide hostility).

One of the more affecting details in those reports – the fact that Lincoln would visit the cemetery alone at night to hold his son’s embalmed body – is the foundation of George Saunders’s fabulous, and fabulously hard to classify, new novel Lincoln in the Bardo.

A brief plot summary: young Willie Lincoln dies, and is interred in a Georgetown crypt. As the narrative begins, he finds himself in a bardo (the word never occurs in the book itself, only in the title), an intermediate place populated by ghosts – or souls, or spirits, pick your word. Its occupants, who are active only during the night, don’t know they are dead (some of them may have dimly suspected this, but they have suppressed the thought) – as far as they are concerned, they are temporarily in “sick-boxes”, waiting to get well and be returned to their former existence, where their loved ones patiently wait.

But when the new arrival’s father, the President himself, penetrates this darkness, it shakes up their sepulchral after-lives (this is something new – the people from “that previous place” don’t open vaults and touch “sick-forms”). Some of the ghosts now attempt to help the confused and lonely Willie, and to communicate – in whatever way possible – with the strange, comically lanky but very magnetic man who is visiting their terrain. In the process they understand new things about their own situation, and deal with it (or don’t deal with it) in different ways.


One-of-its-kind

Critics tend to over-use the word “extraordinary” while describing a book of the moment. I’m happy to fall back on it for Lincoln in the Bardo, not just to indicate its quality and emotional impact but also the apparent ease with which it breaks away from regular storytelling forms. The novel has undergone so much experimentation, in so many directions, over the past few decades (to cite some high-profile contemporary writers, look at the work of David Mitchell or Zadie Smith), that it’s risky to call a new book the “first” in any sort of narrative – but Saunders’s work has as good a claim as any other. A label like “historical fantasy”, while broadly accurate, doesn’t begin to scratch its surface; at the very least, you’d have to add a few further descriptors. (“Absurdist-philosophical, pseudo-journalistic, interior-monologue-cum-narrative poem”?)

Reading it, images and passages from other stories kept running through my mind: the great Michael Powell film A Matter of Life or Death, in which a brain surgery being conducted on earth runs alongside a grand celestial trial (real or imagined?) where nothing less than the meaning of civilisation is debated; or Neil Gaiman’s The Graveyard Book (recently adapted into a multi-illustrator graphic novel), in which a living infant is nurtured by supernatural creatures. But ultimately, Lincoln in the Bardo is a one-of-its-kind.

For one thing, it moves fluidly from the profound to the flippant, and in ways that remind us that the two things aren’t mutually exclusive: when a cemetery watchman offers an amusing description of Lincoln on his mount (“…his legs are quite long and his horse quite short so it appeared some sort of man-sized insect had attached itself to that poor unfortunate nag who freed of his burden stood there tired and hangdog and panting as if thinking I will have quite the story to tell the other horsies upon my return …”), it doesn’t detract from the pathos of the situation.

For another, it merges fantasy – often grotesque, profane, scatological fantasy – with straight-faced reportage. Saunders alternates between his invented otherworldly tale – much of which comes to us in the fascinating voices of two bardo-dwellers, Hans Vollman and Roger Bevins III, who are longtime companions – and fragments from actual news reports, letters and the vast literature about Abraham Lincoln: his presidency, the war, his bereavement, the many perceptions of him during his lifetime.

Some short chapters entirely consist of such fragments, and yet the book never seems derivative, because it carefully uses those sources to build its own distinctive structure and mood, or to create a sense of urgency. There are also contradictions in the historical literature quoted, which is fitting given that this story is partly about the vastness of human experience and the unreliability of our perspectives.

In one chapter, made up of real, effusive accounts of the state dinner hosted by the Lincolns on the night that Willie fell very ill, one report says that a bright golden full moon shone in the sky; another describes “a fat green crescent”; yet another says it was “a silver wedge”; we are also told that there was no moon at all. Similar anomalies occur in a brilliant chapter containing descriptions of Lincoln’s face and eyes.

Blurring lines between categories

In the fictional sections, I particularly liked how the bardo’s inhabitants adopt forms and shapes that reflect their personalities, attachments, or states of mind at the time of death. Bevins III, a suicide who had in his dying moments regretted his act and become aware of the world’s many sensory wonders, now has numerous sets of eyes, noses and hands (with bloody slashes on all the wrists), and can’t keep extravagant descriptions out of his speech. Vollman, who was felled by a ceiling beam as he was anticipating the consummation of his marriage later that night, has a dent in his head but is also naked with a huge swollen penis. A woman who died during a surgery and is worried about her three daughters is surrounded by three gelatinous orbs that alternate between painfully crushing her and abandoning her (which causes even more torment). A landowner fretting about his many properties floats about horizontally, his head facing in the direction of this or that estate.

While this is a fantasy-adventure populated by strange, shape-shifting creatures, it is also a story about the many things we take for granted, our disregard for our own worth and how our lives intersect with those of others. A reader might at first feel pity or revulsion for the restless spirits “trapped” in the bardo, but to experience this book fully is to be reminded that regular existence too – the cycle of birth and death, being confined to our physical bodies, vulnerable to ailments, emotions and self-deceptions – can feel like a trap. The bardo-dwellers are very much like us in many ways: like them, we defensively construct stories for ourselves, repeat the same things endlessly in conversations, play out our essential natures over and over, have no real sense of the passage of time.

Saunders has done a strange and wonderful thing: apart from blurring the line between the (in any case misleading) categories “literary” and “genre” – or “realistic” and “outlandish” – he has created a novel of ideas where the ideas are often spelled right out but the effect isn’t heavy-handed, because this premise and framework seem to require it. Multiple narrators speak to each other and to us, probing, reflecting, trying to make sense of things (picture M Night Shyamalan’s The Sixth Sense told through the accounts of the many bemused ghosts who don’t know they are dead). Gradually, these Greek chorus-like voices come to seem like components of a single shared consciousness. And amidst all this, we also get Abe Lincoln’s agonised musings filtered through the spirits who enter him in turn and relay his words to us. Here is someone responsible for so many lives (and so many deaths), now petrified by his own grief; but ultimately the grief also serves as a catalyst, enabling him to see more clearly.

In these passages, the book cleverly literalises the idea that a conscientious state leader must contain multitudes, must accommodate the perspectives and whims of a variety of people, cutting through the cacophony of voices in his head, streamlining confused thoughts into a series of decisions that may, possibly, bring about the greatest possible good in the long run.

But perhaps part of the point is that you don’t have to be an American president to face such conundrums; we are all leaders in our own lives. As Lincoln in the Bardo draws to a close, there is a powerful scene where the over-descriptive Bevins narrates a list of experiences, from the mundane to the very special, from “milk-sip at end of day” to “the way a moistness in the eye will blur a field of stars” to “someone noticing that you are not at all at ease”, all of which add up in countless ways to make us what we are; and then ends his monologue by saying:

“None of it was real; nothing was real.

Everything was real; inconceivably real, infinitely dear.

These and all things started as nothing, latent within a vast energy-broth, but then we named them, and loved them, and in this way, brought them forth.

And now must lose them.”

It’s as pure a summing up of life’s wonders and prisons (and prisons-disguised-as-wonders, as well as wonders-disguised-as-prisons) as you’ll find in fiction. And it comes in a book that is funny, fresh and imaginative, a story about a president in a moment of private and public crisis (if “bardo” means a nowhere-land where one is uncertain of the way forward, the book’s title has an obvious double meaning), but also about all of us, perched on the junction between flesh and spirit, trying to balance the limitations of one with the possibilities of the other.

Lincoln in the Bardo, George Saunders, Bloomsbury.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.