So Much For That by Lionel Shriver

Lionel Shriver’s So Much for That presents a withering critique of American medical care — and lack thereof — through the story of two families, the Knackers and the Burdinas.

Shepherd Knacker is a good guy. After building his handyman business into a thriving concern, he sold it to employee Randy Pogatchnik for a calculated $1million dollars. Knacker plans to abandon the proverbial American rat race for what he has long called “the afterlife:” escape to a carefully investigated country, preferably third world.

To this end, he and his wife, Glynis, spent years traveling, sussing out the best and worst places. Finally, Shep decides on the island of Pemba, just off the coast of Zanzibar. He is quite literally packing his bags, e-tickets in hand, when Glynis drops a bombshell: she has perotineal mesothelioma. Mesothelioma more commonly occurs in the lungs, and is always related to asbestos exposure. It’s also pernicious, vicious, and incurable.

Shep tears up his tickets and returns to his former business, now dubbed Handy Randy, and watches Pogatchnik, a nasty incompetent, run the business aground. Shep despises Randy, who returns the favor, but Shep desperately needs the job, which provides health insurance for Glynis.

Shep’s best friend, Jackson Burdina, once his business partner, also works for Handy Randy, for the same reason: he needs the health insurance coverage. Jackson’s eldest daugther, Flicka, has Familial Dysautonomia. FD is exceptionally rare, affecting only Ashkenazi Jews. Dysautonomia means the autonomic nervous system—the swallow reflex, digestion, breathing, balance—are not automatic.

FD children live short, terrible lives. They have limited feeling in their extremeties, making childhood injuries life-threatening, compromised lungs that invite repeated infections, acid reflux so severe they vomit daily. Their tear ducts don’t function, requiring constant eyedrops. The lack of taste buds, coupled with swallowing difficulty, make eating near impossible, requiring feeding tubes and costly supplemental nutrition to pour down said tubes. Over time, FD children’s faces deform and their ability to walk deteriorates. Most die by age 20.

Shriver has always been expert at sussing out medical conditions most of us never think about. In We Need to Talk About Kevin, Kevin’s sister loses an eye (I won’t tell you how; read the book) and Shriver writes about mother Eva’s care of the girl’s empty socket with casual expertise. Irina, of The Post Birthday World, suffers from Reynaud’s Syndrome, a vascular problem causing icy hands and feet that go white, bloodless, and numb.

Shriver is a rare thing these days: a writer who has managed to buck the odds. She’s old school: she stuck with writing, even when success eluded her; she’s proud of her work (rightfully so), and each book is stronger than the last. In interviews she is uncompromising, witty, acerbic, sharply intelligent, and fearlessly speaks her mind.

Her very sharpness, which turns up in several of her characters, makes her work a pleasure, as does her sheer reach. Few writers today can write a range from rock percussionists (Checker and the Derailluers) to murderous teenagers (We Need to talk about Kevin, winner of the Orange Prize), to the need to choose between two perfectly good men (The Post-Birthday World), all the while inserting jabs at American versus English speech patterns, a parent’s refusal to recognize a sociopathic child, snooker, and American politics.

Shriver’s characters are fully realized beings who talk a great deal. Flicka is intelligent and sarcastic, doing and saying whatever she can to get a rise out of her mother, Carol, whose constant caregiving has left her affectless. Jackson is the opposite, Flicka’s foil, egging his beloved daughter on as she rails against the stupidity of doing her algebra homework when she is going to die, anyway.

Jackson, who shares Flicka’s bewilderment at Carol’s elusiveness, is a garrulous man given to ranting about a government he loathes. His world is divided into Mugs and Mooches—the numbly accepting masses and those who exploit them, chiefly big government and their fellow henchmen, American medical insurers. He rants endlessly on lunchtime walks with Shep, at dinners with Carol, Flicka, and youngest daugther Heather, even at Glynis’ bedside, at her request.

Glynis, meanwhile, is one of those puzzling women one both admires and loathes. Once a talented metalsmith, she has not worked in years, locked up by her own perfectionist tendencies. She is a lean, angular woman who is precise in matters of line and style. She is also as caustic as she endures the drugs soon pumping through her system — a futile effort to halt the inevitable.

Shep, meanwhile, is such a good guy, so compliant, allowing Pogatchnik to roll over him, his younger sister Beryl to constantly harangue him for money, his father to remain blissfully oblivious as Shep forks over thousands for his care. Worse, perhaps, is Glynis. She spends much of her illness in a state of pure rage, snarling at friends who tentatively inquire “what it’s like,” or at her sisters’ feeble attempts to reconcile. She manages to drive nearly everyone away, though Shriver is careful to name all the friends whose initial offers of help fade faster than unfixed film. If Glynis is unsparing, so is Shriver in documenting the ways people in dire straits find out who their true friends are.

Although Shep and Glynis have drifted apart in recent days, her illness pulls her husband to her side. He willingly forgoes everything, including his own well-being and their financial security, to try and save her. Yet Glynis isn’t the least bit grateful; in fact, she initially fixes her rage on Shep himself, blaming him for her cancer. Which Shep accepts.

The reader wants to smack both of them, proving what a fine writer Shriver is. Yell back! You want to scream at Shep. Instead, you keep turning the pages, for even the finest of men reach their breaking points — and both Jackson and Shepherd do, in wildly differing ways.

Shriver’s stories on the travesty that passes for much of American medical care are infuriating, indeed. The out of membership rejections, the co-pays, the drugs that are ‘off-formulary’: that is, to be paid for out of pocket. Even a wealthy man like Shep may be bankrupted by cancer treatment. Unsurpsingly, he is.

Shriver deserves special credit for her character, Flicka. Writing about a disabled teenager can be a one-way ticket to bathos, unless said child has an incredible mouth on her. Flicka has an opinion on most everything, and is usually right. Only Flicka is willing—and able—to take on Glynis, in a “sick girls only” visit where she pokes holes in Glynis’s survival fantasy, taking liberties only a fellow sufferer can hazard. Gleefully macabre, she sneers at herself, at Glynis, at her classmates, who treat her with deference to make themselves feel good.

Here the sick refuse to suffer quietly, with angelic demeanors. They’re mad as hell. They should be.

Though there is some light at the end of the tunnel, the tunnel is a long one. Anybody who has cared for a sick individual or is chronically ill herself will nod grimly at Shriver’s outraged novel, sniffle in places and wish, indeed, that So Much For That were truly only fiction.