Speculative Fiction and the Political Economy of Healthcare: Chang-Rae Lee’s On Such a Full Sea
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Chang-Rae Lee’s 2014 novel On Such a Full Sea uses the genre of speculative fiction to reflect on longstanding healthcare debates in the United States that have recently crystalized around the Affordable Care Act. The novel imagines the political economy of healthcare in a future America devastated by environmental illness. What kind of care is available and to whom? Who provides it? Who pays for it? What about distribution and access? The different healthcare systems governing each of three geo-social zones in Lee's future society represent exaggerated versions of the scenarios participants in the ACA debate claim their opponents’ health policies would produce. The essay argues that Lee’s novel ultimately favors a version of universal government-funded care over a system based on supposed free-market principles, even as the novel also tries to make room for conservative Americans’ fears about the specter of so-called “socialized medicine.” More broadly, the essay contends that the health humanities should devote more attention to literary and artistic engagements with healthcare as a system: a complex set of financial models, public and private institutions, government policies, and actors whose roles range well beyond patient and care provider.
KeywordsLiterature and medicine Speculative fiction Health policy Healthcare funding Universal healthcare Environmental illness Chang-Rae Lee
The author would like to thank the following for their helpful comments on this essay: the anonymous JMH peer reviewer, Sabrina Barton, Gretchen Murphy, Elijah Barrish, and all spring 2017 participants in the Faculty Fellows seminar on Health, Well-Being, and Healing sponsored by the University of Texas at Austin Humanities Institute.
1 The movement for teaching “structural competency” in medical education is highly relevant to my argument here. At intellectual, pedagogical, and institutional levels, however, structural competency, too, takes clinical education and the clinical encounter as its points of origin (Metzl and Hansen 2014). Within literary studies, the emergent critical paradigm known as “infrastructualism” also relates to my approach in this essay. Critical infrastructuralism thinks “about how fiction approaches and relates to social and political questions of public goods, economic development, governmentality and, as a founding part of the project, a renovation of the concept of the commons” (“Infrastucturalism” 2016). See also Caroline Levine 2010; Rubenstein, Robbins, and Beal 2015.
2 I would like to imagine health policy fiction as providing an opening for the health humanities to involve itself in the education of, for example, medical economists, policy makers, and even insurance executives. Political scientist David A. Rochefort (2014) also employs the term health policy fiction.
3The first half of this paragraph borrows phrasing from Barrish 2016, 108.
4Consider a Trump tweet sent on March 27, 2017: “ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!”
5 Unlike healthcare, many other concrete questions about the set-up of Lee’s imagined future remain hazy, as the late sci-fi writer Ursula K. Le Guin (2014) complained in a diatribe again “literary” writers who attempt speculative fiction without respecting the genre’s full demands.
6When Lee began writing the novel he intended to set it in a present-day Chinese factory town in Shenzhen, which he had researched and visited for the purpose. It was while gazing out his Amtrak window at street after street of boarded-up Baltimore row houses that he determined to change the setting to a future B-Mor populated by Chinese immigrants (Lee 2014c).
7 A JMH reviewer suggested that healthcare in B-Mor may be intended to evoke a corporate-controlled HMO system more than some version of government-controlled socialized medicine. I emphasize the latter reading because of the text’s own emphasis on B-Mor’s healthcare as the single most salient element in the ethos of collectivity that the community takes as its guiding principle, for better and possibly, as Lee’s text also proposes, for worse. Regarding the latter, the most significant potential downsides On Such a Full Sea associates with B-Mor’s healthcare system are not those for which HMOs are commonly criticized—that an overriding concern with the bottom line limits HMO members’ choices and the amount and kind of care for which they are eligible. Although these are indeed features of the B-Mor system, the potential downsides Lee focuses on correlate more closely with long-standing American fears that “socialism” undercuts not only individual choice but individuality as such.
8 Despite its mixed reviews On Such a Full Sea was selected as a finalist for the National Book Critics Circle fiction award.
9 By briefly bringing yet another community into its narrative, albeit a tiny one, On Such a Full Sea emphasizes that the way in which B-Mor’s social programs undercut classic individualism is quite different from the utter annihilation of individuality imagined in Zamyatin’s and Rand’s totalitarian communist states. The community, referred to only as the Girls, consists of seven women, whom a wealthy charter woman has acquired from the open counties and keeps as a kind of private collection. With “utter acclimation to their lot,” the seven Girls abandon their names and use numbers instead. In order to further advance what has become their own desire to merge into a single collectivity, they request that Miss Cathy arrange for them to receive “identically altered eyes” from a plastic surgeon so that they will look as much alike as possible (225, 212). The Girls function in Lee’s novel as a foil to B-Mor: they signal that the social welfare programs of B-Mor, no matter how imperially run they may be, represent at worst a relative diminishment of the sovereign individualism celebrated in American ideology.
10 A reviewer for JMH pointed out to me that Lee’s choice earlier in the novel to use a dialysis machine as an example of healthcare rationing is apt. In the early 1960s, when dialysis machines were new and still scarce, a Seattle hospital became famous for appointing what some called a “God Committee,” which used a metric of “social worth” to decide which medically eligible patients would actually receive the treatment (Levine 2009). Arguably, media coverage of such panels in the twentieth century helped lay groundwork for the conservative fantasy of “death panels” in the ACA.
11 My claim that the health systems portrayed in On Such a Full Sea are speculative realizations of polemical predictions put forth on the U.S. political scene does not preclude the likelihood that Lee’s conception of healthcare in B-Mor is also influenced by international models. The most probable of these is the system of urban Community Health Service (CHS) centers in China, where Lee first planned to set the novel and spent time doing research for it. In this sense, the anti-collectivist tinge I identified above in reviewers’ aesthetic criticisms of Lee’s novel may reflect not only a recurrence of anti-Soviet Cold War propaganda but also contemporary American stereotypes and attitudes towards China. Regarding the CHS system in China, see Bhattacharyya et al, 2011 and Wang et al, 2013.
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