A Fortnightly Review of

Heavy Years: Inside the Head of a Health Worker
by Augustus Young

Quartet Books 2018 | 299pp | £20.00 $25.50

By MARIANNE MAYS.

WHAT’S IN A pseudonym? Jonathan Swift used the name M. B. Drapier as protective cover when he wrote The Drapier’s Letters attacking the British government for its imposition of inferior copper currency. It served its purpose: though many in Dublin knew the Drapier’s identity, no one came forward to claim the substantial reward the Government offered for revealing it. Swift used other pen-names — Isaac Bickerstaff, Lemuel Gulliver — but none became an alter ego. Eric Arthur Blair disliked his name, with its associations with the Victorian novel Eric: or, Little by Little, renowned for its over-earnest piety and moral didacticism. He concocted the name George Orwell: with its very English jaw-jaw sound followed by a satisfying “well” it embodied the ideal of lucid, vigorous plain-speaking style that served him so well throughout his writing life. John Banville invented the alternative persona Benjamin Black as the author of his crime-fiction while retaining his own name for his “literary” novels. Elena Ferrante’s real name remains unknown, despite her supposed outing a few years ago as a female translator based in Rome. Most of her readers are unconvinced by the evidence for this identification. Nor do they care; her anonymity has allowed them to meet her on the neutral ground of her writing, and it has allowed her to concentrate on her writing without the distractions that women writers even more than men are subjected to. She has by-passed the TV appearances, the obligatory glamour photos, the intimacies that interviewers are hungry for, and she continues fiercely to protect her privacy. By using a different though similar name for her first-person narrator she differentiates herself from “the author of the long story we are reading,” and asserts the fictional nature of her work, however much autobiographical material it may contain.

“Augustus Young”, as a very young poet in Cork, needed a pseudonym so as not to “be disgracing the family name” and discovered it in Dryden’s Mac Flecknoe,

———————-. . . who, like Augustus, young
Was call’ d to Empire, and had govern’ d long:
In Prose and Verse, was own’ d, without dispute
Through all the realms of Non-sense, absolute.

The smooth combination of boundless ambition and deflating irony gave him the persona he wanted. I like to think that “Charles Augustus Fortescue,” the hero of Hilaire Belloc’s Cautionary Tales, may also have played a part in his choice: Belloc is mentioned early on in Heavy Years. Young has never — to my knowledge — written under any other name. His most recent publications are Brazilian Tequila and (in verse and prose) the poignant m.emoire.

The narrator is nameless, so readers can no longer assume that he and the author are the same…the pseudonym as a literary device contributes to the reader’s almost subliminal sense of bewilderment.

“You are Augustus? I thought you didn’t exist,” says a character In Light Years (to which Heavy Years is the sequel). It’s a good question. In context, the speaker, who had thought that “Augustus” was a figment of his unstable daughter’s mind, is reassured to find that he is a “real” person. In Light Years, Augustus Young uses the same name for both author and narrator, suggesting that they both exist on the same level of reality, whatever that may be. But when the publisher’s blurb on the cover of Heavy Years says that Augustus Young the prolific writer of poetry, prose and plays “worked as an epidemiologist for thirty years,” isn’t it a bit like saying Lemuel Gulliver was Dean of St Patrick’s Cathedral? At any rate, “Augustus” has disappeared from the pages of Heavy Years: the narrator is nameless, so readers can no longer assume that he and the author are the same. In the gap all kinds of games become possible: the pseudonym as a literary device contributes to the reader’s almost subliminal sense of bewilderment. Who exactly is it whose voice we hear, whose words we read, who emerges from his office in a converted toilet to haunt the staircase and corridors of the institution, with ambiguous role and status, yet influential in many quarters?

In the same way, Heavy Years eludes the nets of classification. Satire, sociology, history, politics, memoir, Irish writing, philosophical meditation: where would a bookseller place it on the shelves? Suspended between genres, it plays by the rules of none. The blurb calls it “autofiction” but the word does not fit. The rules of that game are that you use the same name as writer (at the keyboard), author (on the cover), and first-person narrator, and then stand over what you have written and take the flak. Knausgaard is widely disliked and deplored as well as admired. My Struggle stands or falls by its truth-claims, though people who appear as characters in his story may (and do) dispute his version of it. In Heavy Years “the barrier that divides fact from fiction is often crossed and double-crossed” (the blurb again), so how can it also be the “inside story of the NHS”? A conundrum, but the subtitle provides a clue. Inside this health-worker’s head is an enormous treasure trove of quotation and reference, and out of it comes a sentence, used as the epigraph, from Kierkegaard’s The Law of Delicacy, to get him off the hook: “The author has the right to use what he himself has experienced. But he must keep the truth to himself and only let it be refracted in various ways.”

A book about the NHS could hardly be more timely or relevant than in this year of that institution’s seventieth birthday.

A book about the NHS could hardly be more timely or relevant than in this year of that institution’s seventieth birthday. The story covers the last decades of the twentieth century, tracing the inexorable growth of bureaucracy, with its proliferating superstructures and substructures, its conflicting interest groups and its tangled politics. This is the behemoth into which the narrator is infiltrated by his Mephistophelean mentor Mal Combes, a consultant with an agenda of his own (though it is not clear what that is) who employs him as a researcher on a project “nobody else wants to do,” and, tacitly, as his own Trojan horse: as a neutral researcher “Poet” (as Mal dubs him) will have a point of entry into “the inner circle.” Mal Combes provides him with the lowdown on the established order, from the Powers That Be, the Mandarins, the Eminent Persons Group, and the Great and Good, through the Health Authorities, Lobby Horses, People Who Matter on the Ground and the Upper Echelons, down to the Underlings and the Humans (human resources). He ends his overview with a piece of advice —“know that nobody loves anyone else unless they have to,” ,and then “thumbing devil’s ears ….’Welcome to the portal of hell’.” Thus Poet begins his progress, more pilgrim’s than rake’s, for by this time he has decided that he “had to find a trajectory” of his own. Mal Combes may be his mentor on the swampy ground of the NHS, but “the voices in [his] head” are more important as he searches for “the large idea” he needs. Chief among the voices are Hegel, Descartes, Voltaire, Brunet, Kierkegaard, Schopenhauer (who was “like opening the Bible to tell you what to do”) with contributions from Bentham and Nietzsche and guest appearances by Janáček and Duke Ellington, while films are “my writing on the wall.” But at this particular juncture as he starts his progress, it is the voice of Rudolf Virchow that predominates. Virchow, a German pathologist celebrated in his time but now largely forgotten. His words, “Medicine is a social science, and politics is nothing but medicine on a larger scale,” become his marching slogan (and the second epigraph at the front of this book).

There was nothing revolutionary about Virchow’s basic tenet. The prime object of life is for humans to be as happy and healthy as possible. He was merely prioritising common sense. I decided that while working on the fringes of the established order, I would dedicate myself to asserting his wisdom by indirect action, achieving improvements in the quality of life which would help to invert the primacy of politics over public health. . . . I was looking for a job where I would be able to get life-enhancing things done in a small way if possible without being noticed. . . . my childhood wish to be sight-unseen still prevailed into my middle years. I would quit the mad world of freelance research and find an inconspicuous niche in the mainstream of medicine from which I had hitherto marginalised myself.”

This statement of simultaneous self-definition and self-effacement is pivotal. Ironically, a few pages later in conversation with one of his new colleagues, Michel Foucault’s Birth of the Clinic is mentioned: “‘He’s an extremist of self-effacement,’ Dean sighed, ‘And at the same time cloyingly arrogant.’ That rang a bell.”

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The story from here on tells of his successes and failures in putting his plan into practice on the ground Mal Combes has mapped out for him. “Hell’s portal opened onto quagmire of unhappiness,” the various groups regarding each other with mutual suspicion. The personnel are introduced under semi-allegorical comic names like Stanley O. Kay and Dame Brenda Tabby. The Powers That Be are headed by Dame Sibyl, and later Little John followed by the New Broom. As “the projects person” with an office in a converted gent’s toilet our pilgrim has his base for infiltrating the system. Starting small, and keeping Virchow out of sight, he devises his own research projects into such areas as redundant treatments, obsolete medication, and ways of using computerisation (just coming in) for identifying doctors with unusual death-rates, which he then presents at meetings of the hierarchical Groups. The upper Groups regard him, initially, as a useful scapegoat, but then worry that he’s getting above himself. “The Eminent Persons Group, their iron bottoms newly polished, were firmly in the driving seat.” He has more success with a grass-roots strategy, getting to know the Underlings and the Humans, and achieves a number of small Virchovian adjustments that produce big improvements in the quality of daily hospital life. But success draws the attention of the Eminents. Dame Brenda tracks him down: ”So this is your piss-palace! Very engaging. Are you occupied? . . . The group considers you a useful resource. . . . If you attended our meetings from time to time it would be of mutual benefit.” The freedom of invisibility is threatened further when he finds himself promoted, by default, to management status. ”I wasn’t cut out to be a manager. . . . A manipulator perhaps.”

The end begins long before it arrives. “Virchow doubts” arise when he happens upon an article about elephants losing their teeth and dying of starvation. What if, he wonders, the “edentulous elephants” were fitted with false teeth? Vegetation would be stripped, the land desertified, and the elephants would starve to death anyway. (No need to point out the parallel to the dilemma of the NHS we now know and celebrate.) He stifles his doubts by concentrating on little improvements. There is a problem with an alcoholic maxillofacial surgeon called Lovecraft. Patients and nurses complain about Lovecraft’s erratic behaviour but the success rate of his operations is good. Such cases call for the “strategic sympathy” tactic, whereby “a dysfunctional doctor [is] made to see early retirement due to health as a blessed relief.” Lovecraft responds as expected and within months has found himself a new job on Harley Street. That’s usually the end, but in this case the issue continues . The plot is complicated but the drift is clear; Lovecraft continues on the agenda, postponed from meeting to meeting, fizzling out only when he gets himself deregistered and disappears to a clinic in Turkey. Even then “shades of Lovecraft” remain.

Then, the narrator is knocked off his bike by a white van, shattering his elbow. He has a spell in hospital (his own) and a rehabilitatory charity cycle ride across the holy land (‘Get back on your bike’, says his therapist) When he returns to work four months later he finds all changed by the departure of Mrs. Sibyl and the arrival of the New Broom. There is a new language: “value-added,” “consumer-driven” and “delivering outcomes downstream.” He settles back, determined not to rock the boat “before landing on my desert island, retirement.” But the end arrives suddenly. An enemy from the aftermath of Lovecraft is on his tail, and “I knew I would have to go sooner rather than later.” He writes an article on Virchow for an anarchist journal, and Mal Combes advises him to “Go while the going is good.” The pilgrimage ends “on a soggy note” in a wet car-park, a scene of mingled farce and pathos, and a small, token, victory. The outsider is back outside.

There is a chapter in the middle of Heavy Years on Irishness, “My secret weapon,” the chief credential of Pilgrim’s continuing outsider status as he moves into the mainstream. The ambiguities of being Irish while being permanently resident and fully employed in England would be recognised by many in the same position: the English politeness in avoiding the fact of his Irishness, “at least directly,” while at the same time allowing him to “get away with” remarks that would be frowned on if made by a fellow English person. “‘A breath of fresh air,’ warbled Lady Wilton. But on balance I don’t think she liked draughts.” On a more serious level, “Becoming English in any way was unthinkable” because of his family history, his father having been a prominent revolutionary in the War of Independence. More serious still, his “Autotochthones” — “the old people in my blood” — speak up inside his head on from time to time, as when a “good bad movie,” with a revenge plot in the Liverpool Irish community, brings on an attack of atavistic violent patriotism and the sense of being in enemy territory. “I left the cinema with the dark intoxication boiling in my blood. . . . Only when I hit the frail tenuous light of the high street did I come to my senses.” He’s rescued by his critical faculty — he can see the weakness of the film — and his addiction to word-play: the ‘‘’big’ dropped out of my ambiguities, and I was left with ‘amities’.” There is no ambiguity in in the moving account of the IRA bombing in Regent’s Park in July 1982. He had gone to listen to the lunchtime concert by the Green Jackets band. The bomb went off under the bandstand, killing eight members of the band. As he leaves the Park he writes a slogan on the bridge: “Virchow lives.” Amity prevails.

Irishness is not the only or even the essential element of his self-definition as an outsider. From the start, he feels a stranger in his own family…

Irishness is not the only or even the essential element of his self-definition as an outsider. From the start, he feels a stranger in his own family: ”I wondered what game we were playing, and what the house rules were,” and “It crossed my mind that I could be a changeling.” The Prologue describes a household where family dynamics work at high pressure, while he, the fourth of five children is, or feels himself to be, the catalyst of disturbance. He is sent to one school after another, finally managing to scrape into university. “When my siblings began to have second thoughts about the fool of the family, my mother said, ‘Don’t encourage him. It will go to his hair’.” At Medical School he does well on written papers but not on clinical work because “I became pale and loitering when confronted with bodily fluids.” He is awarded a Bachelor of Medicine on condition he does not continue towards an MD, which would allow him to practice. With this anomalous qualification he is off to London to look for a job as a lab assistant in the big city where he hopes he will be “left alone to get on with getting away with things.” And, he adds, “The idea of living with the ancient Irish enemy excited me too.” The outsider finds his role.

Heavy Years does not fit comfortably into the comparatively recent slot labelled “Irish writing.” His cultural frame of reference — which structures the arena “inside his head” where the real activity of Heavy Years takes place — is revealed through the epigraphs that head the Parts and Chapters. They are taken from, in sequence, Kierkegaard, Virchow, Thomas Wyatt, E. M. Cioran, Rousseau, Ed Dorn, Shakespeare, Brecht, Samuel Johnson. Kafka, Voltaire, La Rochefoucauld and Montaigne. The literary figures quoted or referred in the text include Blake, Shelley, Coleridge, Wordsworth, Milton, Swift, Melville, Lewis Carroll, Hawthorne, Wallace Stevens, Proust, Stendhal, Rilke, Baudelaire and Verlaine, Conrad. Dickens is there, though not by name: the visit to Jo Manders and her ancient mother in their “doll’s house” is surely a mini-homage to the description of Pip’s visit to Wemmick and “the Aged P.” in Great Expectations. Yeats’s “Come away, O human child” is quoted in the Prologue as a childhood memory. Young began writing poetry under the influence of Austin Clarke, experimenting with techniques imported from Gaelic poetry, but his more recent writing does not reflect any specifically Irish influence or trends. An Irish voice, but the choir is the Great European Tradition.

There’s food for thought on every page of Heavy Years. Mal Combes rebukes the narrator at one point for “over-estimating the cultural reference of your poor staff” in his memos. Readers may identify with the staff. But keep your attention on tiptoe, Wikipedia to hand, and you may find this the most stimulating, entertaining and curious book you’ve read in some time.

♦