A Half-Open Door

Almost fifty years since its first publication in 1967, A Fortunate Man, John Berger’s classic account of the life of a solo general practitioner in rural Gloucestershire, has been reissued by Canongate with an enthusiastic introduction by the young Scottish doctor and writer Gavin Francis which quotes passages from the impressive first reviews by figures as illustrious as Tom Maschler and Philip Toynbee (a patient). A Fortunate Man has been praised by everyone from Geoff Dyer to Alain de Botton and even called the best book ever about general practice; and I can recall the names of colleagues who decided to study medicine after reading it in their younger, more impressionable and—dare I say—more idealistic years.

Francis calls the book “a masterpiece of witness” although the witness is now historical, since communities and their physicians in Britain have been utterly transformed from the largely stable social structure of the immediate post-war period (until 1979), in which GPs were key players, into today’s money-driven, interlinked, “on the go” society. In the first forty years of the National Health Service GPs were legally responsible for the care of their patients, twenty-four hours a day, and sometimes did yeoman service too, looking after them in the local hospital or old folks’ home, or delivering their offspring.

Though the NHS was socialist in inspiration, being forced through by the energetic Aneurin Bevan in the historic Labour government that came to power in 1945, there was always an element of Disraeli’s one-nation conservatism about general practice: it emphasised the social obligations of those in the higher echelons—or at least of the patrician class to which most doctors belonged—of a hierarchical society to those below (noblesse oblige). The doctor was a fiduciary for the patient, and it was accepted that he or she would act solely in the patient’s interests. This kind of moral seriousness—a very British variety of institutionalised altruism—thrived until a more individualistic era decided it was “paternalistic”.

It is worth remembering that the British Medical Association, the professional body that still represents nearly all doctors in the United Kingdom, stood in outright opposition to Labour’s plans to create the National Health Service on the basis of national insurance payments: only about 10 per cent of doctors polled in 1948 were in favour of the new bill. The NHS was, above all else, a political idea. In a time of rationing and relative penury of resources in the immediate post-war period, government moved to create a taxation-based structure that freed GPs, for the first time, from the financial anxieties of having to run a medical practice as a small, usually home-based business (see A.J. Cronin’s once very popular doctor-novels).

Despite the profession’s initial mistrust of government intentions, doctors now tend to be among the staunchest supporters of the system of universal coverage introduced by the Labour government and which Disraeli’s political successors—“Conservatives who conserve nothing”, to quote Flaubert—have been trying to dismantle, mostly on the sly, and replace with American-style health provision. The 2012 Health and Social Care Act with its compulsory tendering and restricted contracts effectively marked the end of the NHS in England (if not in other parts of the UK, which now enjoy, if only to a limited degree, a measure of devolved power). Only neoliberal ideology or naked self-interest can explain why politicians would want to replace a relatively low-cost system (the UK spends less than the European Union average on health care) with one modelled on US systems of healthcare provision that notoriously swallow so much in resources, being far more bureaucratic and inefficient than the NHS (which is free at point-of-use), and deliver so comparatively little in terms of comprehensive services. In the American reality, unpaid medical bills are the principal cause of bankruptcy.

Now, everyone seems to believe “society” needs micromanaged accounts of what its members fork out for services. Although harassed and pressured in their daytime working hours, GPs are considerably better off than before—Marx would have recognised them as a very special group of high-earning “wage labourers”—while being subjected like everyone else to the Taylorism of standard-setting bodies, government targets, accountancy spreadsheets and referral “gateways” in a way Berger’s subject would have found intolerable. Rather than guaranteeing the marginal conditions that might allow the profession to flourish, the state and its representatives intervene so directly in the profession that self-regulation (which used to be one of the definitions of a profession) seems an antique concept. The urban panopticon that is contemporary Britain even extends into the surgery. Except in the more remote parts of the UK one is now very unlikely to encounter a physician like the man Berger calls “Dr John Sassall”, seemingly on call for his local community at any time—“He sleeps easily, but at heart, he welcomes being called out at night.”

In Sassall’s heyday, the 1950s and 1960s, general practice was open-ended and even exciting, as doctors—like anthropologists in the field—put together a body of practical and theoretical knowledge about social conditions and their relation to health and illness that existed nowhere else in the world. Having been traditionally at the bottom of the medical pecking order, general practice began to attract some sharp minds. John Fry (born Jacob Freitag) established an “evidence-base” in his own practice in Beckenham long before anyone else thought to make it a methodology, and debunked such fashionably dangerous procedures as tonsillectomy; Michael Balint was a psychiatrist who studied the doctor–patient relationship in depth and convinced GPs—whose opinions had never been especially cherished by their hospital colleagues—that they were “experts” on their patients; and Julian Tudor Hart, a stalwart advocate of the socialist founding principles of the NHS, came up with the “inverse care law” at his practice in Glyncorrwg: this law states that the availability of medical care varies inversely with the need for it, especially when exposed to naked market forces.

What is still striking about A Fortunate Man is how, in six weeks of shadowing his charge around the clock, Berger not only formed a bond with Sassall but gained insight into the nature of his professional activities and standing in the community. His was the peculiar respect enjoyed by a relatively new addition to the pantomime of British national life: “the unconventional doctor”. He is the representative of a unified, rational medicine but as one of the most prominent personalities in his social group embodies some of the qualities of the ancient healer.

John Sassall (not his real name) started on his career as a kind of master mariner who loved dealing with emergencies—he had served in the navy during the war and been a great reader of Joseph Conrad—before maturing into a physician of exemplary tact and sensibility: if it was still a matter of “doctor knows best” in those days, Sassall offered his patients a candid kind of fraternity as “an ideal brother”. He knew how to listen without interrupting, and it is safe to say he never fobbed his patients off with anything resembling a “checklist”. Berger—clearly fascinated (as perhaps only an intellectual can be) by the spectacle of a professional man absorbed in the mystery of his job—observed, in a famous phrase, that his patients allowed him, in a capacity both intimate and curatorial, to be “the clerk of their records”. (Now, disgruntled GPs call themselves “check-list clerks”.)

The book opens with a series of vignettes which describe events involving Sassall in his “unusually well equipped” surgery, with its anaesthetic apparatus and sterilising equipment (for minor surgery), and on home visits to patients or attending emergencies. The degree of commitment shown by Sassall to his patients, as well as his professionalism and sympathy, are exemplary. “Sassall, with the cunning intuition that any fortunate man requires today in order to go on working at what he believes in, has established the situation he needs.”

That situation, it emerges, is one of full imaginative engagement with himself as well as his patients. It is not clear to what extent Berger puts thoughts in Sassall’s head (rather than words in his mouth): speculations about the nature of life in a community are supplemented with a smattering of references to cultural luminaries of the 1960s such as Sartre, Piaget and Gramsci, which date the book as decisively as Jean Mohr’s photos. Berger discusses Sassall’s depressive phases, but doesn’t provide any insight into his domestic circumstances. It is unfortunate (since it contradicts Sassall’s insistence on the complexity of doctor–patient dealings) that the local Forest of Dean inhabitants—who should properly be called “Foresters”, not “foresters”—sometimes come across as faceless members of the Great British Public, although some of the vignettes offer moments of humour and insight: I particularly liked the one about the “female” partner in the long-married couple who, on examination at home by Sassall because of “bleeding from down below” (owing to haemorrhoids), turns out to be a man. The incident of the displaced genitalia was thereafter passed over in silence by all parties concerned, including Sassall.

Berger refines his key notion of witness. When we call for a doctor, he writes:

we are asking him to cure us and to relieve our suffering, but, if he cannot cure us, we are also asking him to witness our dying. The value of the witness is that he has seen so many others die. (This, rather than the prayers and last rites, was also the real value which the priest once had.) He is the living intermediary between us and the multitudinous dead. He belongs to us and he has belonged to them. And the hard but real comfort which they offer through him is still that of fraternity.

Living intermediary or go-between: that is an inspired and possibly mischievous reading of the psychopomp or soul-guide function once attributed to the god Hermes, wielder of the caduceus that is still associated with the medical profession. (More intriguingly, Hermes was also the trickster god whose services could be called on as the chief protector of shepherds, gamblers and market thieves.)

The impression of the book’s being a product of its time is heightened by Mohr’s black-and-white images, one of which catches Sassall standing in a doorway (and has now been placed—rightly I would say—on the dustcover of the Canongate edition)—a telling image in a book about inner and outer landscapes, as in Robert Frost’s poetry, where “meaning is meant just to elude you going out as you come in” as the poet wrote in a letter to Harriet Monroe in 1917: a doorway signifies an abyss of possibility. Or as an old saw has it, the man who closes a door is not the same as the one who opens it. (Sassall himself talks of opening doors and the supreme importance of “the first contact”, even though he sometimes feels he’s “in the valley of death”.)

While Mohr’s photographs will not be to every-one’s taste, being austere and grainy (though presented in this book with less contrast and to a higher resolution than in previous editions) and consequently reminiscent of how the NHS mothered a residual puritanism in British culture, with its various stoic figures suffering in silence, bent in acceptance or attending deliverance, I was intrigued to read (in the graphic design magazine Eye) that the book is now considered a design classic, owing to its layout by Gerald Cinamon, with words and pictures building on each other, as in a conversation.

Being delivered as images, Mohr’s suite of photos is sometimes more immediately telling than Berger’s text; and I must confess—reading the book again more than twenty years after my last reading—that some of Berger’s insights now seem to be working too hard at significance. The large double-page spread that opens the narrative proper shows a scene with two men fishing from a boat on a placid river somewhere in the Forest while the accompanying script reads:

Landscapes can be deceptive. Sometimes a landscape seems to be less a setting for the life of its inhabitants than a curtain behind which their struggles, achievements and accidents take place …

A landscape as a set of drapes? It seems a forced analogy: surely Berger didn’t think it was his task to burst in on the Foresters in the hidden recesses of such private lives as they might have aspired to? It makes him sound like that Spanish devil Asmodeus, who took the roofs off people’s houses in order to spy on what was going on within. And here he wants to do detective work on an entire topography!

It must also be said that the obscured personages and loose ends in A Fortunate Man now draw attention to themselves, not least Sassall’s wife, who is not mentioned at all in the text and whose presence appears to have had far more bearing on Sassall’s professional life than Berger allows. She was, after all, his support system—practice manager and presumably receptionist too. And as Sassall’s “valley of [the shadow of] death” quote suggests, he is a man on tenterhooks. Perhaps Berger’s six weeks weren’t quite long enough to detect the telltale signs of a cyclothymic illness, with its successive highs and lows. In his introduction Francis tells us that Sassall’s wife’s unexpected death caused him to abandon his practice and travel in China “learning the ways of the barefoot doctors”—which seems an inappropriately extravagant response to the death of a spouse. To imagine that Chinese rural medicine might be a “people’s medicine” (by analogy with the NHS) in the years after the Cultural Revolution when there was a concerted drive to remove ownership of knowledge from anybody who appeared to be an “expert”, suggests an oddly detached kind of primitivism.

And we learn nothing about the circumstances of Sassall’s even more troubling suicide, with a firearm, fifteen years after the book’s first publication, which adds a taste of wormwood to the title. Doctors, like their patients, are only ever half-open beings.