Suchita Shah: Malaria in the Little Novels of Sicily and why we need literature in medicine

suchita_shah“And you feel you could touch it with your hand—as if it smoked up from the fat earth, there, everywhere, round about the mountains that shut it in, from Agnone to Mount Etna capped with snow – stagnating in the plain like the sultry heat of June.”

With these words Sicilian writer Giovanni Verga begins a short story, “Malaria,” thought to be the first fictional depiction of the disease that threatens half the world’s population. Part of a collection called Little Novels of Sicily, this little gem of literary realism was first published in 1883 and later translated into English by D H Lawrence.

In Verga’s rustic literary landscape, based on the villages of his childhood, a man is “reduced to skin and bone,” with “a big belly like a drum.” This man dies, but the disease “doesn’t finish everybody.” In the same place lives a “simpleton,” whom the malaria, “after it had eaten up his brain and the calves of his legs, and had got into his belly till it was swollen like a water bag . . . left him as happy as an Easter day, singing in the sun better than a cricket.”

The imagery here is memorable; it hints at the potential neuropsychiatric consequences of cerebral malaria in those who survive, and at the wretchedness of those who don’t. You might think this blog is going to be about scolding the medical textbooks for not employing such evocative language—but it’s not.

My single recollection about malaria from medical school is that life cycle drawing. You know, the one we all assiduously memorised then promptly banished to some faraway part of our brain (where it probably still lives, companionably sharing dust with the Krebs cycle). For that reason alone I used to wish that every textbook would read like a novel, but maybe I would have learned better had I read this:

“Suddenly the patient feels inexplicably cold (in a hot climate) and apprehensive. Mild shivering quickly turns into violent shaking with teeth chattering. There is intense peripheral vasoconstriction and gooseflesh. Some patients vomit . . . Finally, a drenching sweat breaks out and the fever defervesces . . . The exhausted patient sleeps.” [Oxford Textbook of Medicine, p 730]

The above example would challenge criticisms that all traditional medical textbooks lack imagination, or use dry, obfuscating language. In fact, Verga’s own literary works—detailed, precise, outwardly neutral—resemble elements of modern scientific writing. Verga’s world is no bucolic idyll.

What has actually moved me about this short story, and the first reason why I believe we need literature in medicine, is its ability to capture the social essence of a disease.

The languor that pervades a malaria ridden village, once experienced, rarely is forgotten. But did a medical textbook ever tell you about it? Is the scientific literature able to convey how malaria kills wives and children, ruins livelihoods, and alters whole communities? How it is a sad reality that dead girl children are less important than the boys who “died just when they were getting old enough to earn their bread?” And how, despite all this, “wherever there is malaria there is earth blessed by God;” that the very same land and water that host such destruction also provide sustenance? Social commentary like this can be explicit or implicit in many works of literature (by “literature” I am referring here to fictional prose and poetry), but it is rarely present in traditional textbooks of disease.

Secondly, literature has the capacity to teach, or enhance, empathy. Much has been said about this and its role in medical education. I wonder, though, whether putting too much emphasis on this point risks reinforcing the dichotomy between logical, “cerebral’ science and emotional, “visceral” art. In an attempt to bridge these perceived gaps, parallels have been drawn between literary methods, like interpretation, and narrative medicine. The American philosopher Drew Leder argued that “clinical medicine can best be understood not as a purified science, but as a hermeneutical enterprise: that is, as involved with the interpretation of texts.” [Leder D. Clinical interpretation: the hermeneutics of medicine. Theor Med. 1990;11:9–24.] So, whether it speaks in poetry, prose, or p values, it tells a story of human suffering and attempts to alleviate it.

But what if literature goes beyond merely infusing empathy into medical veins, or providing wider social commentary or interpretive tools, and actually actively contributes to shaping medicine?

Just as authors such as Verga and the realists were influenced by science, so too did scientists and physicians read prose and poetry, which included stories of disease. Joseph Conrad, for example, was penning descriptions of malaria from Europe’s colonies, Henry James from America. Whether, and to what extent, these activities had an impact on medicine is debatable, but what is clear is that the development of modern western medicine happened within a specific social, cultural, and environmental context. And this, finally, is where literature can serve another, more subtle, purpose.

Postcolonial and postmodern literature, and beyond, are possibly the most neglected so far in the medicine humanities discourse. Take Amitav Ghosh’s The Calcutta Chromosome. This challenges us to recognise that the concept of “tropical medicine” was born from a colonial account of history. Such perspectives, which don’t have to be about medicine, can allow us— modern readers and modern doctors—to cast a more critical eye on its epistemology, to question its ethical basis and claims to “truth,” and to challenge its ideological supremacy over alternative traditions. Not to undermine or discredit, but to raise awareness—as even Verga’s Sicilian realism does—that there are different ways of being, and different ways of knowing.

Declaration of interests: the author likes to read. A lot.

Suchita Shah is a family doctor based in Oxford. She has a background in public health and international relations.

Competing interests: Nothing further to declare.