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SIMONE'S ONCOPINION

Dr. Rieux and the Plague

Simone, Joseph V. MD

doi: 10.1097/01.COT.0000312325.62208.8b
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I have written many times about physicians, both those I admire and those I do not. They include fictional characters, historical figures, and a few who are my contemporaries. This focus is based, of course, on my being a physician, but more specifically it is sustained by a curiosity of how we physicians behave in our daily work and also when faced with extraordinary circumstances. How we value our work and interpret its meaning, how we view patients and colleagues, and how we interpret our responsibility and relationship to patients are endlessly fascinating to me. Perhaps this is a perpetual attempt to examine my own behavior as a physician and how it has compared with those physicians I admire, whether real or fictional.

In a correspondence about my book with my friend and colleague Dr. Joe Jacobson, he asked me if I thought Dr. Bernard Rieux belonged in my pantheon of admirable physicians. Rieux is the key character in Albert Camus's novel The Plague, which was published in 1947. I had read it decades before Joe Jackson's question, but had forgotten many details. By chance, I saw a paperback copy in a used book store in the Raleigh-Durham Airport; I bought it for $3.50 and read it.

Here is the basic story: The setting is the city of Oran in Algeria in the 1940s. Algeria had been a colony of France for more than 100 years, and the French population dominated the commercial and political life. (Think of the setting of the movie Casablanca in the adjacent country, then called French Morocco.)

In April, dead rats started appearing everywhere and, after a period of denial, it became apparent that the cause was bubonic plague. The plague progressed, with deaths rising steadily; hospitals filled up and various civic facilities, including a football stadium, were converted to quarantine sites. The pneumonic form of plague appeared later, and eventually the city of several hundred thousand was itself quarantined with no entry or exit permitted, cutting off inhabitants from loved ones and trapping unlucky visitors.

On the framework of the evolution of the plague over 10 months, Camus masterfully examines the changing adaptation of the inhabitants. He uses the detailed development of a few characters to address the issues, personal and public, that they faced and how they dealt with them.

Dr. Rieux cares for the plague patients as best he can, mainly by lancing painful buboes, the characteristic purulent lymph nodes. There were no antibiotics, and an experimental serum was used late in the epidemic with dubious efficacy. He made house calls and sent the infected to the hospital if lancing didn't help, which was the case for most. He worked day and night. The medical staffs were stretched and many developed plague themselves.

At a key moment in the book, his neighbor and friend, Jean Tarrou, suggests they enlist volunteers to help with the medical duties. In this setting, conversations among Rieux, Tarrou, and others gradually reveal how each has arrived at his personal approach to the catastrophe.

In the beginning, once Rieux became convinced that it was indeed the plague, he knows that his patients will die despite his ministrations. And if some did survive, his care would not be the main reason. In spite of this, and the substantial risk to his own life, he continues to do the best he can for the patients both personally and by supervising nurses and volunteers.

During a conversation that centers on why each has chosen to help the afflicted, Tarrou asks Rieux whether any good comes from the plague, such as opening man's eyes and forcing him to take stock. Rieux responds, “What's true of all the evils in the world is true of plague as well. It helps men to rise above themselves. All the same, when you see the misery it brings, you'd need to be a madman, or a coward, or stone blind, to give in tamely to the plague.”

Rieux then says, “Yes… but you haven't answered my question yet. Have you weighed the consequences [of volunteering to help]?”

Tarrou responds, “Do you believe in God, doctor?” Rieux answers, “No—but what does that really mean? I'm fumbling in the dark, struggling to make something out. But I've long ceased finding that original.”

Tarrou presses him, “Why do you yourself show such devotion, considering you don't believe in God? I suspect your answer may help me to mine.”

Rieux then says that no one believes in an all-powerful God because no one threw himself on Providence completely. He believed himself to be on the right road—in fighting against creation as he found it.

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Figure:
Joseph V. Simone, MD, is Clinical Director Emeritus of Huntsman Cancer Institute, Professor Emeritus of Pediatrics and Medicine at the University of Utah, and President of his own consulting company (www.SimoneConsulting.com). He was previously Physician-in-Chief of Memorial Sloan-Kettering Cancer Center and Director of St. Jude Children's Research Hospital, and has served as Medical Director and Chairman of the National Comprehensive Cancer Network, Chairman of the Institute of Medicine's National Cancer Policy Board, and as a member of the NCI's Board of Scientific Advisors. Dr. Simone welcomes comments about this column, as well as suggestions for future topics. E-mail him at OT@lwwny.com

‘There Are Sick People, and They Need Curing’

“I have no idea what's waiting for me, or what will happen when all this ends. For the moment I know this; there are sick people and they need curing. Later on, perhaps, they'll think things over; and so shall I. But what's wanted now is to make them well. I defend them as best I can, that's all.” And Tarrou asks, “Against whom?”

“I haven't a notion, Tarrou; I assure you I haven't a notion. When I entered this profession, I did it ‘abstractedly,’ so to speak; because I had a desire for it, because it meant a career like another, one that young men often aspire to. And then I had to see people die. Have you ever heard a woman scream ‘Never’ with her last gasp? I was young then, and I was outraged by the whole scheme of things, or so I thought. Subsequently, I grew more modest. Only I have never managed to get used to seeing people die….since the order of the world is shaped by death, mightn't it be better for God if we refuse to believe in Him and struggle with all our might against death, without raising our eyes toward the heaven where He sits in silence?”

Tarrou: “Yes. But your victories will never be lasting; that's all.”

Rieux: “Yes, I know that. But it's no reason for giving up the struggle.”

Tarrou: “No reason, I agree. Only, I now can picture what this plague must mean to you.”

Rieux: “Yes. A never ending defeat.”

Above All, a Committed Healer

There is much to admire in Dr. Rieux. He is kind, selfless, and heroic. Most of all, he is humble. Like many physicians and all surgeons, he is a doer, a man of action. He can discuss his philosophy and atheism (or agnosticism) with understanding for those who believe. He is, above all, a committed healer and irrespective of philosophy or theology, he must do the “right thing,” he must do his job. He works to exhaustion and yet continues.

We may see him as a hero, but he does not see himself as one. Near the end of the book, in response to a comment about the never ending losses and deprivation of both the sick and the healthy populations, he says, “But, you know, I feel more fellowship with the defeated than with the saints. Heroism and sanctity don't really appeal to me, I imagine. What interests me is being a man.”

Rieux certainly is a man, a man in full. And despite his protestations and theology, he is also a hero and a saint.

© 2008 Lippincott Williams & Wilkins, Inc.
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