by Nick Major

THE SRB INTERVIEW: GAVIN FRANCIS

August 10, 2016 | by Nick Major

The quality of Gavin Francis’ books belies the fact that writing is not his only occupation. Born in Fife in 1975, he qualified from medical school in Edinburgh in 1999 and spent ten years travelling around the world.

In 2008 he published his first book, True North, which recounts a trip through Arctic Europe, taking in the Shetland Isles, Greenland, Iceland and Lapland. A trademark of Francis’ writing is not only his pellucid prose style but his ability to weave science, mythology, history and literature into his work. His second book, Empire Antarctica: Ice, Silence & Emperor Penguins, demonstrated a similar polymathic quality. It saw him swap the polar north for the south. Unlike the Arctic, which ‘has been written about for more than 2,000 years…the imaginative tradition of Antarctica is still young and pliable’. Francis spent fourteen months as the base-camp doctor at Halley, the British Research Station on the Coast of Antarctica, sharing this white canvas of a landscape with fourteen other staff and 60,000 Emperor Penguins.

For the time being he leads a more settled life. Now a practising GP in Edinburgh, his book Adventures in Human Being won the Saltire Non-Fiction Book of the Year Award for 2015. It swaps the icy poles of the earth for the co-ordinates of the body. It is as much a history of the body through art as it is a history of the body through science. Francis also writes reviews and essays. One of his most recent pieces for the London Review of Books tells of a visit to the Edinburgh Mortuary. He is Guest Selector at this year’s Edinburgh International Book Festival, for which he has organized a series of events about literature and medicine.

Nick Major met Gavin Francis in Edinburgh’s Surgeons’ Hall Museum in an alcove of the pathology section dedicated to Charles Bell, the nineteenth-century artist and anatomist whose personal art and medical collection formed the basis of the Museum. Overlooking the pair of them were Bell’s paintings of the war-wounded, bodies in various states of disrepair. There was an air of religious quiet in the building as visitors to the museum tip-toed around the hall, staring into display cabinets at the medical curiosities, almost as if the preserved body parts therein were individual sites of benediction.

True to his profession and his wandering feet, Francis is a worldly and a down-to-earth man. He came straight from his GP clinic in Newington, and was dressed smartly in a white shirt, yellow tie and black trousers. In his early forties, he wears his years well. Clean shaven, and calm-mannered, he had a reassuring voice and spoke using considered, precise language. One sensed that his patients were never far from his mind, even when he was eloquently discussing the work of Jorge Luis Borges or Sir Thomas Browne.

Scottish Review of Books: At the beginning of Adventures in Human Being you write that as a child you wanted to be a geographer, not a doctor. Why did you change course?

Gavin Francis: To me there were a lot of similarities. I wanted to be a geographer because I loved being out in the landscape, and I also loved the kind of vicarious travelling it’s possible to do through maps. I used to spend hours leafing through a world atlas, or over Ordinance Survey maps. I was very moved by the idea that maps give order to the world – they render the complexity of the world around us into something intelligible. Then someone gave me a map of anatomy, and there were tremendous aesthetic and intellectual parallels between the two kinds of atlases. I saw there was also an inner landscape that could be mapped and mastered. When I was interviewed for medical school, at seventeen, I told them that I wanted to learn all that I could about how the body is put together.

Why did you choose Edinburgh University?

I chose Edinburgh because my brother was at Napier, and Edinburgh was familiar because I grew up in Fife. It was a kind of old-fashioned medical course, very traditional, and that appealed to me very much. At that stage it was all pre-clinical science in the first two years. It wasn’t until the third year that you went on to the wards. There’s a lot spoken now about how it’s better to get medical students straight on to the wards, but there are plenty of eighteen-year-olds who are not emotionally equipped for that. I’d have been happy at any of the Scottish medical schools, though recently they’ve been shown to have a poorer record than English ones in taking kids from state schools. Edinburgh also has the lowest proportion of graduates who turn to general practice, which strikes me as odd. I’ve always found general practice to offer the most interesting intellectual challenges, as well as a high level of autonomy, in comparison with my time in medical specialties.

Did you have any aspirations at that age to write?

Not at all. I had an aspiration to travel and see the world. I hoped that one day medicine might give me a trade to be able to travel anywhere in the world, and find work. It’s done that for me, and on those travels I used to read shelf-loads of travel and nature books – Annie Dillard, Paul Theroux, Robyn Davidson, and Bruce Chatwin. It became natural for me to want to write a book that I’d most want to read. As I get more experienced the clinical, personal contact of medicine becomes more important. There’s no way I’d want to give that up to write exclusively.

You once worked in a hospital in Tibet, and write about sending patients down the road to a traditional clinic if they had ‘unusual constellations of symptoms’. Have other, traditional approaches to medicine influenced your own practice?

I think there are universals about the way humans respond when we are in distress, whether physical or mental. It’s wonderfully reassuring to see that in action in different cultures. For example, I saw traditional bone-setters in West Africa inspiring more confidence in their patients than the Western-trained medics. Most medical traditions believe in an element of physical examination, which is partly about looking for illness, but is also about reassuring the patient, and inspiring confidence.

And you were on the road for roughly ten years?

Only on and off. Between 1999 and 2008 I would travel for a few months at a time, then work back in the UK for a few months, incrementally getting experience in emergency medicine, general practice, and various medical specialties. When I worked for the British Antarctic Survey I was sent for a six-month block of training in the military hospital in Plymouth, then I was away for sixteen months overseas, first as a ship’s doctor sailing the length of the Atlantic, to the Falkland Islands, then down to the Antarctic for a year, and back again. Between 2006 and 2008 my wife and I drove a motorcycle from Orkney to New Zealand.

The Antarctic journey you mentioned is in Empire Antarctica. One thinks of doctors as sociable people, so why did you want to go to such a desolate place?

I don’t think there’s a contradiction there. You can love the human contact of a busy medical practice and still love silent and austere landscapes. For me it wasn’t a retreat from the world, or from the interpersonal aspect of medicine. It was a deliberate choice to advance into a very different, elemental place. Antarctica is phenomenally beautiful, just light and ice, and I wanted to see it through the changes of all its seasons. I was also curious to know what would happen if I stopped for a year. I’d always been on a treadmill of jobs, travels, and exams. I hadn’t really stopped my whole life. To go somewhere for a whole year, a very beautiful place, where there is nothing in the way of distractions, was quite monastic. I had a year of no demands on me at all – my fourteen patients were all fit and well.

Did you write there?

I wrote my first book, True North, when I was there.

Did you go to the frozen south knowing you would write about the frozen north?

No, I had never written before. I’ve always been a voracious, omnivorous reader and, as I said, there was a part of me that wanted to write the book I would most enjoy reading.  I had never had the chance, with the hectic nature of medical training, and this was my opportunity because for the first time in my life I had all this time on my hands. It was like an ocean of time ahead of me – a tremendous luxury. So I looked at diaries of a trip I’d made round the Arctic a couple of years earlier and started to write. It was a pleasant surprise how much I enjoyed the process; I’m not one of these writers who find the experience torturous – it’s recreational, otherwise I wouldn’t do it. That book found a publisher with Polygon, and I enjoyed the whole thing so much I wanted to write another book, this time about the Antarctic. At that point I was working very hard at medicine, so I applied to the Scottish Arts Council, as it was then, and they gave me a bursary to take some time away from the clinic. So that was how Empire Antarctica was written. It was written in South Queensferry.

Those are two very different environments to write in. 

Sometimes in my shed, in the winter of 2010, it felt like the Antarctic. I had to wear my polar boots.

How long do you spend on research? Does it take more time than the writing?

It depends – sometimes research is everything, and I’ll spend weeks reading around a subject before writing a chapter.  It’s such a luxury to have the National Library of Scotland on hand, to call up editions of just about any text you care to choose.  Recently I was writing an essay about bodybuilders for my next book, and being able to call up Arnold Schwarzenegger’s autobiography, for example, was a treat. And friends who are academics help me out with papers from obscure journals. Some of the travel writing takes no research at all, just my memories and journals. The LRB piece you mentioned, about watching autopsies in the Edinburgh mortuary, took just a couple of hours to write while the memory of it was fresh.

Do you write every day?

No. I’m in a clinic three days a week so I can only write the other two days while the kids are at school. I wish I could write in the evenings but I’m always brain dead by 8pm.

What’s an average day like as a GP?

I get up around 6.30am. I’m out the door by 7.30am. I pedal into Newington and I do paperwork from 8.30am until 9am; I see patients until 11am. I do more paperwork until midday and then I’m out doing home visits from 12.30pm until around 2pm, during which I grab lunch. I have more patients from 2.30pm until 5pm and more paperwork until 6pm. My writing days are more relaxed.

Obviously you think about medicine when you’re writing, but do you ever think about writing when you’re practising medicine?

It’s an interesting question. Doctors use words all the time. Half the treatment of a patient is about explaining their own problem back to them, and offering a convincing explanation of how they might get better. There’s also an extraordinary amount of recording of consultations. Every consultation – and I do about thirty a day – has to be written up afterwards. Medical language needs to be quick, articulate and concise. There’s an art to writing referral letters too. So there’s a huge amount of writing in my medical day – I don’t feel medicine and writing are mutually exclusive at all. That’s part of this strand of the Book Festival that I’ve been guest selecting this year: I would argue that there is a synergy between medicine and literature, and that both have a lot to offer one another. I do believe that being a writer makes me a better doctor, and I’m certain that being a doctor makes me a better writer. The poet William Carlos Williams was a doctor, and he wrote a beautiful essay where he said that ‘as a writer I have never felt that medicine interfered with me but rather that it was my very food and drink, the very thing which made it possible for me to write. Was I not interested in man?  There the thing was, right in front of me.’ Medical practice can be extraordinarily nourishing for a writer because if you’re interested in humanity, there it is, all the time, knocking on your door, ‘incorrigibly plural’ as Louis MacNeice said.

What can doctors learn about the body through art that they can’t learn through science?

It’s not particularly easy to pin down exactly what doctors should be taking from the Humanities. I think these things are so personal, that different kinds of art or literature help different people. It’s not that there’s a specific thing to be learned, but that engaging with the arts and with culture helps doctors imagine the worlds of their patients so much better, and also helps them emotionally to refresh themselves and avoid burnout. If you’re able to engage with different kinds of literature, and different historical, metaphorical, mythological and experiential perspectives on the body, then you’re much more likely to be able to talk to a broad range of people, convince them you have diagnosed their problem, and have solutions to help them get better. There’s a lovely quote from one of the Latin playwrights, Terence, that says: ‘I am a human being, nothing human is alien to me.’ There’s a vast panoply of humanity out there, and there are countless different ways of going about living your life. As a doctor you see them all – a tremendous privilege – and if you are skilled and well-practised and open to engaging with all these different ways of living, then you’re likely to be much better at your job, and go on enjoying it.

You talk about Charles Bell in the book, whose paintings are around us. Did he use painting as a way of understanding the body?

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A painting by Charles Bell in Edinburgh’s Surgeon’s Hall Museum of a man suffering from tetanus.

I’m not an expert on Bell, though I’ve read some of his letters, and looked at many of the stunning paintings he made after Waterloo and the Battle of Corunna. He wrote a beautiful book about the hand, which, because of its intricacy, he took as evidence of the existence of God. From what I understand about Bell he was disgusted by the appalling quality of the anatomy textbooks of his day, and his first love was art. He didn’t want to be a doctor, he wanted to be an artist, but his family were all doctors so he was forced into the profession. His older brother was the chief surgeon at the Royal Infirmary and so the pair of them set about creating a new anatomy textbook using Bell’s drawing skills. My last book talks in particular about his interest in expression using the facial muscles, and how artists can learn from anatomy and physiology how to accurately represent emotion in the face.

Fiction writers are notoriously predatory. They can do what they want with a person’s story, protected by the form they work in. Writing non-fiction seems to have an added moral dimension, and more so if you are a doctor with a Hippocratic responsibility. Do you find it easy to write with that ethical weight on your mind?

I wouldn’t say it was difficult, though it is very important. On the very first page of Adventures In Human Being I state quite clearly that the following stories are grounded in clinical experience, but that nothing within them is going to be recognisable to anybody. I have a duty of responsibility to all my patients to know that they can come to me without their stories being used in some way. I don’t really accept the distinction between fiction and non-fiction. As you said, all novelists steal from real life. Somebody in my position who is taking from real life, making it accessible but having to change it, is essentially fictionalising in order to make a character unrecognisable. So there is an enormous grey area where fiction and non-fiction meet. We are both taking from truth and taking from invention in similar ways, but we’re coming from different directions.

Have you ever prescribed literature?

In a few different ways. I have certainly prescribed poems. For example, there’s a lovely Ben Okri poem called ‘To an English Friend in Africa’ which I can recommend to anyone going to work in developing countries. I’ve prescribed William Styron’s Darkness Visible to people suffering recurrent black depressions. The City of Edinburgh Council Libraries produces a list of self-help books which have been recommended by psychiatrists and psychologists. I have a list I hand out to patients and tell them to get certain things from the library. But I probably have to know a patient quite well before I advise them to go read Styron or Annie Dillard or Hilary Mantel.

You write about Jorge Luis Borges, whose blindness was a catalyst for his imagination. Literature seems to thrive on illness. Do you find that an uneasy idea? 

We all face adversity in our lives, and artists respond to it with art. Borges is a great example. He mourned  the loss of his sight in some places, but in others he said he would never want his vision back, and that the life he had been granted by blindness was very rich. He explored all that wonderful Anglo-Saxon language and those Old Norse texts only after he became blind. For some people illness can be a release into a different kind of life – think of Darwin’s neurasthenic retreats, when his illness offered him a get-out clause from the society he preferred to avoid so that he could get on with thinking. But, I recognise for most people illness is something to be endured and survived. There is a paradox, however, in that some aspects of ill-health can drive creativity. There’s a famous conversation recounted by Edvard Munch, who had a lot of mental health problems. When he was offered a cure for his ills, he said: ‘They are part of me and my art. They are indistinguishable from me, and it would destroy my art. I want to keep those sufferings.’ Munch certainly didn’t want to be cured. Most people do, because their mental health problems bring only distress and anguish.

Considering that my grandparents’ generation were less likely to think of themselves as ill than my generation, how far do you think illness is a state of mind?

There’s no doubt that increased willingness to attend doctors with worrying symptoms is a very good thing. I don’t mourn the old days of people hiding fungating breast tumours under their blouses for years because they were ashamed of them – it’s a good thing that we’re getting past that. But the phenomenal success of Western medicine has led to the over-medicalisation of things for which Western medicine doesn’t have a great deal of answers. So our successes have led to over-confidence and over-prescription, and because so many drugs are effective we have started to see the restitution of our bodies through pills for conditions that are just part of normal life. Perhaps advertising is to blame, but it’s perfectly normal not to feel happy all the time.

Is that more of a problem for psychological than bodily illness?

No, you wouldn’t believe the number of people who take anti-cholesterol pills but still eat bacon sandwiches. Or diabetics who eat chocolate biscuits twice a day but think that’s OK because they take a pill. That’s an example of over-medicalisation. A lot of people would argue that doctors should act more as police for that, but that’s not my role. I’m not here to police people’s self-control.

You are introducing a book called On Immunity by Eula Biss at the Edinburgh International Book Festival. Is immunisation an example of over-medicalisation?

No, immunisation is an interesting one. I reviewed that book for the Guardian, and I thought it was a very original approach to a difficult problem, written with extraordinary sensitivity by a woman who genuinely had a difficulty with immunisation, but instead of giving in to her anxieties decided to fully inform herself of the science. Humans have always dreamed of becoming invulnerable – it goes all the way back to Achilles, being dipped into the river. There always that chink, that little bit of the heel that we can’t manage to protect, and immunisations also have chinks in their armour. I was very moved by that approach to immunisation, and by her very dogged and rigorous assessment of evidence for and against. We live in such a healthy society now, largely because many childhood illnesses have been eradicated through immunisation programmes, and we have better hygiene. But some people have started to think they no longer need to immunise their children, and when that reaches a certain proportion of the population, those diseases come back. It’s the conclusion Eula Biss comes to at the end of that enthralling book. We’re going to talk about it along with Chitra Ramaswamy’s book [The Inner Life of Pregnancy], which takes a hybrid approach to examining the medical, personal and cultural aspects of pregnancy. That kind of memoir, which draws on science and culture, appeals to me very much.

You’re holding a reading workshop on Oliver Sacks’ The Man Who Mistook His Wife for a Hat at the Book Festival. 

The Man Who Mistook His Wife for a Hat was originally a diary piece for the London Review of Books, in 1983. The book takes twenty or so essays, many of which were originally published in the New York Review of Books or the London Review of Books, and takes you on a grand tour of Sacks’ preoccupations with neurological problems as a window on how we experience the world. He looks at deficits, like the prosopagnosia of The Man Who Mistook His Wife for a Hat, and excesses, like Tourette’s Syndrome, which gives tics and odd vocalisations – although sufferers also have faster reaction times. Then he moves onto ‘Transports,’ visionary states of mind brought on by things like temporal lobe epilepsy or drug-induced psychoses. Finally, he looks at what would now be called learning disabilities, and how the traditional neurological way of looking at learning disability is much too limiting. A lot of the patients in his care were consigned to long-stay residential homes because of low IQ, but they had wonderful and highly-developed skills in other areas, which he helped to reveal.

Did Oliver Sacks approach his patients in a way that wasn’t the norm when he started?

Yes, I think so. He was the resident doctor in an old-fashioned care home, and devoted an enormous amount of time getting to know his patients. He didn’t have an office and a brass plaque, with people queuing at his door; he lived in the home with them, and talks movingly about how such places can be asylums in the best sense – the sense of offering safety and a retreat. In his autobiography he says he spent long periods where he was there seven days a week, eighteen hours a day. When I was a medical student in the mid 1990s I wrote to him, asking if I could go and do a placement with him. He wrote a very gracious reply telling me he was too busy, and by then was seeing far fewer patients than he’d like to have been.

In your introduction to A Fortunate Man, John Berger’s account of the country doctor John Sassall, you said you give it out as gifts. Is that because Sassall was so exemplary in terms of the relationships he had with his patients?

I give it for various reasons. I have given it to doctors who were getting disillusioned with the job in the hope of reigniting some inspiration about how valuable their profession can be, and I’ve given to people who have no direct experience of medicine because it’s a masterpiece of witness. It’s a beautifully observed representation of what happens in a clinical consultation, something that has been done very rarely, and when it has been done, it’s usually been done by doctors, who are probably not the best people to drill down into the social and interpersonal dynamics of what’s going on.  But someone like John Berger, who has very highly-trained observational skills from his work as an art commentator, was the perfect person to write such a book. He’s interested in the doctor-patient relationship at the personal, professional and hierarchical level, and its wider implications for the community. He says in the epilogue, written after Sassall committed suicide, that Sassall was a great friend, that he loved him and that he was devastated when he died. But Berger takes the Greek view, that we shouldn’t think of a suicide: what went wrong? How could we have stopped it? We should instead look at Sassall’s suicide as part of his destiny, which is a very controversial view to take, but a view I respect in many ways. I wouldn’t agree with it, however, for some of my own patients who have committed suicide.

You also said the kind of doctor-patient relationship in the book is disappearing. Can you elaborate?

I have this very strong sense that roles in society are changing. Doctors are no longer put on pedestals, which is a good thing. Medicine is seen increasingly as a service rather than a profession, and people are more demanding of services. If you take night call outs [from the time John Sassall was practising] and you graph them, you see that as the decades went by doctors were getting called out more and more at night. The population wasn’t getting more ill at night, there was just this building sense that the doctor’s job is to see us when we’re ill, and if that’s in the middle of the night they should get out of their beds and see to it. But that meant the job became harder and harder to do as a single doctor. So to do what John Sassall did – be on your own, on call every night, and see your patients all day – gradually became impossible. But then, when telephones were invented some doctors said, ‘telephones are going to be the end of our profession, because now we’ll be called up for all sorts of rubbish’. If you’re seen as a service rather than a profession then it gets it harder and harder to manage that commitment twenty-four hours a day, seven days a week. It’s incredibly rare now to find people working the way Sassall did. You still find it in the Highlands and Islands, but the doctors still doing that are for the most part managing small populations of a few hundred people, rather than what Sassall did, which was cover a couple of thousand. There are some lovely things about working the way Sassall did, but there are also some terrible things.

From the outside, the NHS always seems to be in crisis. What’s the view from the inside? Is it becoming a better place to work?

Oh no, it’s definitely getting harder and worse. It’s just economics: our governments don’t sanction the same level of investment in the health service as they do in France, Germany or Holland or Denmark. So we have this tremendous success story of an aging population, with (of course) increasingly health needs, but we don’t have the concomitant investment needed to cope with that. Sadly, I see us increasingly moving to a two-tier system, even in Scotland. More and more people who can afford it are starting to go private because waiting lists are so long, from lack of investment. We just don’t value the NHS enough to vote in politicians who’ll give it the commensurate proportion of GDP that it requires.  We’re always told that the NHS is unaffordable, but that’s actually a lie – we’ve the most efficient and admired health system in the world, which has been starved of funds.  Politicians have got to decide whether they want to continue with the same philosophy of the forties, the founding principles of the NHS, or whether they decide they want to give up on that ideal just because the costs are greater.  Either you raise money for it through better and higher taxation or cutting other services (or nuclear weapons), or you allow the NHS to go into a two-tier system with people who can pay and people who can’t, like the U.S.

To return briefly to Adventures.
You show that some treatments have their origins in the imagination rather than in science. Was one of the ideas behind the book to track the progress of those treatments?

Yes. We tend to think that all our understandings of the body came out of the Enlightenment, but ancient Greeks thought that mood disorders came from a problem of the brain. I was keen to express the sense that although there has been a tremendous success from the scientific revolution, a lot of the things we do, and the places our understanding comes from, are much older than we give them credit for. I was keen to explore the landscape of how our ideas of the body came about, because they still influence us enormously.

And in terms of the science, is the body still uncharted territory?

We’re still finding out unbelievably intricate aspects of how the genetics of every cell in our bodies actually works. We are finding out new things about the brain, about growth and healing, about cancer, and the immune system. Our understanding of how the body works is always changing.

At the end of the book there is a wonderful quote from Sir Thomas Browne: ‘Life is a pure flame, and we live by an invisible sun within us’. Taking your work as a whole, the variety of authors you refer to is astonishing. Where do you get the time to read Sir Thomas Browne, for example?

There’s no magic answer to that I’m afraid: I read all the time, whenever I’ve the chance. There are always a couple of books in my bag and, in a slack moment, I’ll manage a page or two. Even when I was at high school I’d be reading while queuing to get into the classroom.  Thomas Browne’s language is tricky, but wonderfully so. He uses neologisms that are not in any dictionary, and then there are passages that are just transcendental. He had a wonderful mind, a tremendous breadth of reference, could think laterally and vertically and obliquely – and he was interested in everything.  I was rereading Religio Medici recently and there’s this passage when he wants to say he’s not interested in gold, or profit, but instead of just saying that, he says: ‘To that subterraneous idol and god of the earth, I do confess I am an atheist.’

Your own prose is often full religious language. 

When trying to articulate a sense of wonder or awe I think it’s natural to use religious language. I’m no theologian, but the language of the Bible can be very powerful when we are groping around to express deep issues about life and death, and when we are looking for ways to articulate a sense of magnificence about being alive. Browne again, in Religio Medici,  says: ‘we carry within us the wonders we seek without us’ – that’s a good way of to sum up the awe it’s possible to feel when thinking about human anatomy and physiology.

That brings us nicely to endings and your account of visiting Edinburgh Mortuary. 

The visit came organically from a conversation. I was speaking to one of the pathologists  about a mutual patient who ended up having a post-mortem. I said I envied her being able to see what was really happening under the skin. She said, ‘most of the time we can’t figure it out either, but we do gather important clues’. She asked me if I would like to have a look, so I did. I thought it was a very useful thing for me to do: some of my patients go to have post-mortems, and as a GP, their wider families remain my patients, and I’m often involved in trying to help them through their grief.  I was very impressed with the skill and professionalism of the pathologists, and hope that comes through in the piece. It doesn’t matter whether I’m writing about the Antarctic, or the Himalayas, or neurosurgical theatre, or even what happens in an autopsy, my writing aims to cross a boundary on behalf of the reader, and describe for them something they would never otherwise experience.

From this Issue

ADDICTED TO PRINT

by Alan Taylor

God Bothering

by Brian Morton

EVA: Six Poems

by Michel Faber

Road to Somewhere

by Todd McEwen

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