Notebooks Esteve Foundation 42

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notebooks Esteve Foundation 42

Television fiction viewed from the perspective Medicine in Television Series of medical professionals

House and Medical Diagnosis. Lisa Sanders Editor: Toni de la Torre The Knick and Surgical Techniques. Leire Losa

The Sopranos and Psychoanalysis. Oriol Estrada Rangil

The Big Bang Theory and Asperger’s Syndrome. Ramon Cererols

Breaking Bad and Methamphetamine Addiction. Patricia Robledo

Mad Men and Tobacco Addiction. Joan R. Villalbí

The Walking Dead and Epidemics in the Collective Imagination. Josep M. Comelles and Enrique Perdiguero Gil

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series. Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Nip/Tuck, Grey’s Anatomy and Plastic Surgery. María del Mar Vaquero Pérez

Masters of Sex and Sexology. Helena Boadas

CSI and Forensic Medicine. Adriana Farré, Marta Torrens, Josep-Eladi Baños and Magí Farré

Homeland and the Emotional Sphere. Liana Vehil and Luis Lalucat Series Medicine in Television

Olive Kitteridge and Depression. Oriol Estrada Rangil

True Detective and the Attraction of Evil. Luis Lalucat and Liana Vehil

Polseres vermelles and Cancer. Pere Gascón i Vilaplana

ISBN: 978-84-945061-9-2 9 788494 506192 42 NOTEBOOKS OF THE ESTEVE FOUNDATION Nº 42

Medicine in Television Series

Editor: Toni de la Torre Cover illustration by Suxinsu (www.suxinsu.com).

English version: Kevin Booth for ANKER Traductores

This edition expresses the opinions of its authors, which are not necessarily the views of the Fundación Dr. Antonio Esteve

ISSN print edition: 2385-5053 ISSN e-edition: 2385-5061 ISBN: 978-84-945061-9-2 Legal deposit: B-10216-2017 Printed in Spain The Fundación Dr. Antonio Esteve (Esteve Foundation), established in 1983, has the main aim of encouraging progress in Pharmacotherapy through communication and scientific discussion.

The Foundation wishes to promote international cooperation in pharmacotherapeutic research and, to that end, organizes international multidisciplinary meetings where small groups of researchers can discuss the results of their work. Such discussions find an outlet in various publication formats such as the Esteve Foundation Symposia and the Esteve Foundation Discussion Groups.

Other Esteve Foundation activities include organizing meetings to discuss problems of a more local scope, published as monographs or notebooks. The Foundation also participates in conferences, sem inars, courses and other forms of support of the medical, pharmaceutical and biological sciences, not least among which is the Research Prize, granted biennially to the best article published by a Spanish author within the field of pharmacotherapy.

Striking among the variety of publications that the Esteve Foundation promotes is the series Pharma- cotherapy Revisited, which compiles the main articles that laid the foundation of a specific discipline in several volumes, in facsimile edition.

-III-

Notebooks of the Esteve Foundation Nº 42

Contents

Introduction Toni de la Torre...... 1

House and Medical Diagnosis Lisa Sanders...... 11

The Knick and Surgical Techniques Leire Losa...... 19

The Sopranos and Psychoanalysis Oriol Estrada Rangil...... 29

The Big Bang Theory and Asperger’s Syndrome Ramon Cererols...... 35

Breaking Bad and Methamphetamine Addiction Patricia Robledo...... 49

Mad Men and Tobacco Addiction Joan R. Villalbí...... 55

The Walking Dead and Epidemics in the Collective Imagination Josep M. Comelles and Enrique Perdiguero Gil...... 61

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet...... 69

Nip/Tuck, Grey’s Anatomy and Plastic Surgery María del Mar Vaquero Pérez...... 75

Masters of Sex and Sexology Helena Boadas...... 85

CSI and Forensic Medicine Adriana Farré, Marta Torrens, Josep-Eladi Baños and Magí Farré...... 93

-V- Contents

Homeland and the Emotional Sphere Liana Vehil and Luis Lalucat...... 97

Olive Kitteridge and Depression Oriol Estrada Rangil...... 103

True Detective and the Attraction of Evil Luis Lalucat and Liana Vehil...... 111

Polseres vermelles and Cancer Pere Gascón i Vilaplana...... 117

-VI- Notebooks of the Esteve Foundation Nº 42

Authors

Josep-Eladi Baños Josep M. Comelles Doctor in Medicine Specialist in Psychiatry from the Universitat Autònoma de Barcelona Founder of the Master’s in Medical Anthropology Specialist in Clinical Pharmacology and International Health, and of the Doctorate from the Hospital Clínic de Barcelona in Medical Anthropology Lecturer in Pharmacology at the Experimental at the Universitat Rovira i Virgili and Health Sciences Department (CEXS) Professor Emeritus at the Medical Anthropology at the Universitat Pompeu Fabra Research Center of the Universitat Rovira i Virgili Barcelona Tarragona Helena Boadas Toni de la Torre Sexologist and relationship therapist Critic of television series Writer and columnist for the Diari de Girona Author of the books Series de culto Girona and J.J. Abrams: la teoría de la caja Ramon Cererols Collaborator in El Món a RAC1, Arucitys Author of Descubrir el Asperger and La Vanguardia Conference speaker on Autism Spectrum Lecturer in Scripting Series Disorders at ICE of the Universitat de Barcelona, at the Universitat de Barcelona Universitat Internacional Menéndez Pelayo in Member of the jury of the Ondas Awards Barcelona, Mental Health Unit at the Consorci Barcelona Sanitari de Terrassa, Confederación Autismo España and several associations Oriol Estrada L’Ametlla del Vallès (Barcelona) Graduate in Psychology and holds a Master’s in East Asian Studies Aina Clotet Founder of the Espai Daruma Actress Culturally disperse writer and educator Graduate in Audiovisual Communication Mataró (Barcelona) from the Universitat Pompeu Fabra Barcelona Adriana Farré Bonaventura Clotet Researcher at the Instituto de Neuropsiquiatría Director of IrsiCaixa y Adicciones (INAD) and in the Neurosciences Head of the Infectious Diseases Service Program at the Institut Hospital del Mar at the Hospital Germans Trias i Pujol d’Investigacions Mèdiques (IMIM) Badalona (Barcelona) Barcelona Marc Clotet Actor Graduate in Company Administration and Management; holder of an MBA from ESADE Barcelona

-VII- Authors

Magí Farré Lisa Sanders Researcher at the Instituto de Neuropsiquiatría Associate Lecturer y Adicciones (INAD) and in the Neurosciences at Yale University School of Medicine Program at the Institut Hospital del Mar Columnist for the New York Times Magazine d’Investigacions Mèdiques (IMIM) and Well Blog Lecturer in Pharmacology Inspiration and technical consultant in the Faculty of Medicine for the series House MD at the Universitat Autònoma de Barcelona New Haven (CT), USA Head of the Clinical Pharmacology Service at the Hospital Universitari Germans Trias i Pujol Marta Torrens Badalona (Barcelona) Researcher at the Instituto de Neuropsiquiatría y Adicciones (INAD) and in the Neurosciences Pere Gascón Program at the Institut Hospital del Mar Director, Molecular and Transnational Oncology d’Investigacions Mèdiques (IMIM) Laboratory at the Institut d’Investigacions Barcelona Biomèdiques Agustí Pi i Sunyer Head of the Medical Oncology Service María del Mar Vaquero at Hospital Clínic de Barcelona Doctor in Medicine and Surgery Barcelona Specialist in Plastic, Aesthetic and Repair Surgery Luis Lalucat Editor of the magazine Cirugía Plástica Ibero- Doctor and Psychiatrist Latinoamericana Director of the “Les Corts” Mental Hygiene Center Sociedad Española de Cirugía Plástica, Barcelona Reparadora y Estética (SECPRE) Federación Ibero-Latinoamericana de Cirugía Leire Losa Plástica (FILACP) Graduate in Medicine and Surgery Madrid from the Euskal Herriko Univbertsitatea (University of the Basque Country) Liana Vehil Specialist in General and Digestive Surgery at Clinical Psychologist the Hospital de Sant Joan Despí Moisès Broggi Coordinator of the Rubí Community Barcelona Rehabilitation Service, Consorci Sanitari de Terrassa Enrique Perdiguero Gil Terrassa (Barcelona) Senior Lecturer in History of Science at the Universidad Miguel Hernández de Elche Director of the University Master’s in History Joan R. Villalbí of Science and Scientific Communication Head of Quality and Processes at the Universidad Miguel Hernández de Elche at the Barcelona Public Health Agency Elche (Alicante) President of the Tobacco Consultation Council at the Health Department of the Patricia Robledo Government of Catalonia Senior Scientist Associate Lecturer in the Experimental and on the Neurosciences Program at the IMIM- Health Sciences Department Hospital del Mar de Investigaciones Médicas at the Universitat Pompeu Fabra Barcelona Barcelona

-VIII- Notebooks of the Esteve Foundation Nº 42

Introduction

Toni de la Torre

Medicine and television series have been sym- of representation on television, with the doctor’s biotically conjoined for more than half a cen- white-coated figure most commonly identified as tury. Of all dramatic genres in serialized fiction, the hero in TV series. the medical genre is the one most firmly rooted This popular perception was also consolidat- in the origins of televised fiction. It is one of the ed by the fact that the presence of the medical foundational genres of the series and, in contrast drama in serialized format has been a constant to the western (inherited from film), and the sit- for decades. The genre had its premier in 1951 com (hailing from radio), medical drama formed, with City Hospital1 on CBS, the first series in the alongside police series and legal drama, a type of genre. Since then, there has always been a medi- fiction inherent in series, that came into existence cal series on air in the US, with the sole exception with the medium. These are known as workplace of a four-year period from 1956 to 1961 (from the programs (fictions set in the workplace), whose last episode of NBC’s Medic to the premier of Dr. structure arose with the earliest television series. Kildare on the same channel). From 1961 to the Their construction is closely linked to the creation present, US viewers have always had reference of the narrative language of this new medium, to a fictitious hospital, making the medical pro- which until recently was considered a lesser me- fessional a constant figure in the collective imagi- dium, albeit highly popular. Doctors, the police nation created by television2. The genre, far from and lawyers were the main stars in this format becoming jaded, has managed to reinvent itself of televised fiction, and doctors tend to be more over time –as we will see in this book– and its frequently identified with the world of TV series. popularity remains strong even in the new era of Such an association is due to two reasons. TV series, in which they have achieved unheard- Firstly, it is a question of clarity. Lawyers and of prestige. The arrival of new ideas and risky cre- police have often shared a screen in the same ative series have not shouldered medical dramas series, both genres frequently overlapping (a aside. In the midst of this creative revolution in paradigmatic example is that of Perry Mason, TV series, as many as three medical series have who practices as both a lawyer and detective), been on air at one time. From 2005 to 2009, the while the medical drama has rarely mixed with veteran show ER, the recently launched House other genres, remaining more sharply defined. and Grey’s Anatomy, still on air, were being The second reason can be found in the medi- broadcast on NBC, FOX and ABC respectively. cal drama’s preference for the serialized format. All three attracted a large and loyal audience, While police drama has had a prolific presence good reviews in the press and the recognition of in film (even more so than on the small screen), the television industry, the three shows collecting medical practice has found its foremost means 32 Emmy Awards between them.

1 Throughout this volume, italics will not be used for the names of series, since there are too many and this would interfere with com fortable reading of the book. 2 On the next page, see the chronology of the main medical series broadcast in the US from 1953 up until the present.

-1- Introduction 2015 The Knick (2014-Present) 2010 Nurse Jackie (2009-2015) 2005 Grey’s Anatomy Grey’s (2005-Present) House M.D. (2004-2012) Nip/Tuck (2003-2010) 2000 Becker (1998-2004) 1995 ER (1994-2009) Chicago Hope (1994-2000) Dr. Quinn Dr. (1993-1998) 1990 Northern Exposure (1990-1995) 1985 China Beach (1988-1991) St. Elsewhere (1982-1988) 1980 1975 Quincy M.E. Quincy (1976-1983) CHRONOLOGY OF THE PRINCIPAL MEDICAL SERIES IN THE US MEDICAL SERIES IN THE PRINCIPAL CHRONOLOGY OF 1970 M.A.S.H. (1972-1983) Marcus Welby Welby Marcus M.D. (1969-1976 Medical Center (1969-1976) 1965 General Hospital General (1963-Present) The Doctors (1963-1982) 1960 Dr. Kildare Dr. (1961-1966) 1955 Medic (1954-1956) 1950 City Hospital (1951-1953)

-2- Notebooks of the Esteve Foundation Nº 42

Medicine in Television Series

Of all three fictions, ER tends to be consid- tious series Prescription Passion, which is a par- ered the medical drama of reference, not simply ody of General Hospital) and others which have for the number of awards it has reaped during nothing to do with the genre, such as Friends. its lifetime (of those 32 Emmys, it won 23) but (The character Joey, who is an actor, gets the because, furthermore, it is the fiction in its genre part of a doctor called Drake Ramoray, who is that has been longest on air in the US, with 15 simultaneously a parody of one of the doctors in seasons and 331 episodes. Its figures lag be- General Hospital, Dr. Noah Drake, and a parody hind the British program Casualty, which is the of another soap, Days of Our Lives, broadcast longest-running medical drama: it was launched on NBC, the same channel as Friends.) When on the BBC in 1986 and is still on air. In its time, all is said and done, General Hospital is the se- it was the English answer to the North-American ries that most helped consolidate the hospital as St. Elsewhere3, a founding medical drama that a fictional setting, consequently shoring up the standardized the forms of the genre in the eight- medical drama genre in the North-American tele- ies. Nevertheless, Casualty is less able to exert vision tradition. influence than North-American medical dramas, which are exported to numerous countries and The hospital as a dramatic setting end up playing a greater role in forming collective imagination concerning medicine worldwide The medical drama has its basis in the very foun- than television generates. (In this respect, it is no dations of serial fiction, characterized by offering different to other genres since the predominance viewers an episodic narration that develops over of the North-American television industry is abso- time (a far longer period than in other media, and lute in terms of fiction exports.) naturally much greater than in film) and follows the Only General Hospital surpasses both ER and lives of specific characters in a stable universe. Its Casualty in duration, but they are not generally serial nature is defined to a certain extent by rep- compared like to like given that General Hospital etition: In each fictional episode, viewers encoun- is a soap set in a hospital rather than a medical ter a number of repeated elements, starting with drama, a crucial difference for many reasons. (The the same theme music (the repetition of which technical expertise, acting quality and creativity fulfils a ritual function), the same characters, the in the soap opera genre are far below drama in same place and often, moreover, the same man- terms of quality, and in fact, the manner of film- ner of resolving plot conflicts. This repetition has ing and broadcasting are completely different, as soothing effects on viewers –who enjoy witness- well as viewers’ perception of them.) Neverthe- ing the development of what they already know, less, that does not mean that this medical soap’s something which has elements they can more or resilience in US programming, where it launched less predict– and constitutes the key to the cre- on ABC in 1963 and still airs (over 13,000 epi- ation of a fictional universe that is stable in time. sodes broadcast), is not a good example of the The universes created in TV series have fea- ongoing presence of hospital fiction on television, tures that tend to seek viewers’ well-being, be- or of the unquenchable popularity that medical ing spaces in which viewers want to lose them- stories have among viewers4. selves. One of the fundamental rules of classic General Hospital is also the most referenced series is the use of resources that aim to encour- medical series, to the point where it even appears age viewers to return each week to see the next in other hospital series such as House M.D. (Dr. episode. That means creating universes one House never misses a single episode of the ficti- wants to be a part of –at least for the duration

3 Broadcast in Spain under the name Hospital and in Catalonia with the title A cor obert. In Latin America it was called Hospital San Eligio. 4 This is in contrast to other founding genres in TV series, such as the western, which despite the huge popularity it enjoyed in the fifties, sixties and seventies, ended up being shunned within the medium. Nowadays westerns hold a residual position, the main contemporary examples of the genre being Deadwood, Hell On Wheels and Justified.

-3- Introduction

of the broadcast– and characters one wants to professional work. In medical dramas, the cen- get to know. Naturally, I am referring, above all, to tral character in this plot type is a patient, whose the series from the fifties and sixties, which was story is presented, developed and resolved in an when the medical drama was created. In later episode. Meanwhile the storylines of the hospi- series, the techniques for capturing the audi tal medical team evolve. They are the true main ence’s attention were adapted to other ways of characters, but their plot lines often have more understanding serial fiction. So, the cliff-hanger to do with their personal than their professional or change of direction in the script are two of the life. Sometimes, a patient’s storyline may have a most popular in contemporary series, where the stronger influence on one of the stars, acting as repetition of elements and stable universes have the detonator to a conflict, serving as a parallel to given way to the fiction of innovation. something that is happening in the doctor’s per- These stable universes have their origins in sonal life, or showing a new facet of his or her the television set’s domestic nature, prompting personality, especially when dealing with medical the medium to create fictions that seek viewers’ cases with an ethical conflict. In specific cases, comfort. In such universes, audiences find a sec- the episodic storyline can transform the protag ond home of which they form part every time they onist, but that is not its main function. sit down to watch. The universes in traditional se- This division between professional and private ries are Arcadias boasting an established order life has been a feature of medical dramas since that can definitively be altered only with difficulty. their beginnings: Part of the interest generated Viewers know that a conflict that endangers the from exploring the daily goings on in a workplace nature of the universe in question is possible (for is in getting to know the workers intimately (not example, an argument between two characters), just their occupational side). Nevertheless, the but they also know that in most cases the con- use of spaces has varied over time. In series in flict will be resolved to ensure that the universe the fifties and sixties, the universe of the medi- remains unaltered. In the classic serial structure, cal drama was divided in two: One part of the such universes have a huge capacity for resist- story evolved in the hospital and another part at ing change (to the extent that time appears sus- the medical professional’s home, a legacy of the pended, without characters progressing on in family series, which was very popular in its day. their lives as they would were they real), while This was the structure followed by one of Spain’s the contemporary series take more risks and most successful medical dramas: Médico de Fa- introduce changes over the seasons that alter milia. Its storylines in Doctor Nacho Martín’s hos- the series’ universe. Whenever an event of this pital were blended with the character’s daily life at nature occurs, such as the death of one of the home as a father and head of the family. The hos- protagonists, it is traumatic for viewers because pital as a space for fiction gained in prominence the fiction in which they live through the television in medical dramas from the eighties onwards, set changes for good. with the North-American series St. Elsewhere. The medical drama (and other variants of Here, the building became a place with its own workplace programs) use a story type that in life, another character in the series through which television script slang is known as episodic to hundreds of people’s lives circulated. So it en- introduce dramatic events that do not greatly af- joyed a life independent of its protagonists. This fect the main characters and so do not alter the new structure, more focused on the setting where universe of the fiction. Normally, they tend to be the medical profession was practiced, is what the related to non-habitual characters, used only in a series Hospital Central adapted to Spain. This is specific episode, and arise from the characters’ the latest successful medical drama in Spain5.

5 Note that the trends governing TV series tend to reach Spanish television late, since Médico de Familia was launched in 1995 and Hospital Central in 2000, both much later than the international series that inspired them.

-4- Notebooks of the Esteve Foundation Nº 42

Medicine in Television Series

The growing importance of the hospital space westerns or the detective in police series. This in medical dramas is reflected in the treatment says a lot about the way the television medium it receives in fiction. It goes from being a neutral has traditionally represented doctors: as heroes space that could be any hospital (from standard- who save lives, but who, instead of using a re- ization) to a place with its own personality (per- volver or showing a sheriff’s badge, wield a sonification). It is easy to mention the names of scalpel and white coat as symbols of authority. some of these fictitious institutions and for view- Doctors perfectly fit the definition of the clas- ers to know perfectly well which series we are sical television hero in the sense that their cause speaking of. Names such as St. Eligius, County is noble and their nature altruistic. They tend to General Hospital, Princeton-Plainsboro Teaching value others above themselves, sacrificing them- Hospital and Seattle Grace have become associ- selves to long working days and always doing ated with medical dramas that used the hospi- everything possible to save their patients. The tal as the epicenter of its fictional universe. The archetype of the healer notably underscores the North-American series St. Elsewhere was the portrait of the television doctor, whose capacity first medical drama to foreground the hospital in- to heal those who need it makes them a figure to stitution, in a change that formed part of a trend admire and in whom viewers can blindly lay their in televised fiction that had begun a year earlier faith. The sheriff protects us from the Indians, the with Hill Street Blues –both series were by the police inspector from criminals and the doctor same producer, MTM Enterprises. The focus on from diseases. At heart, they all look out for our the hospital enabled the medical drama to sink its safety. This is an idea that connects with comfort roots into a particular neighborhood with a spe- fiction, which we mentioned above, converting cific socio-economic situation, broadening the the medical professional into a character with a type of comment that could be made as a genre. friendly and understanding disposition. This point will be developed below. The protagonists of the early medical dramas, Within series set in workplaces, there is no such as Dr. James Kildare (from Dr. Kildare), were doubt that a hospital is a unique venue to create the prototype of a doctor for whom a reassur- scenarios that hold narrative possibilities. This is ing smile and a slap on a patient’s back were not just because it is a space through which an in- enough to gain their trust. “It’ll all be fine” was finite number of anonymous individuals may pass what the character played by a young Richard (meaning an infinite number of possible story- Chamberlain conveyed. His faculties surpassed lines), but because, furthermore, the stories un- those of a medical professional. Despite his men- folding in such a setting tend to have great dra- tor, Dr. Leonard Gillespie, warning him that he matic potential. It is also a setting that appeals to should limit himself to the sphere of medicine, the viewers of all kinds because conflicts linked protagonist in this classic medical drama often to health connect to a broad audience. Health is took his medical practice further and became his a common concern among audiences that are a patients’ advisor, such was the sense of security priori highly diverse. The doctors and medical he transmitted. So we are dealing with an author- team are at the drama’s epicenter and are the ity figure to whom are attributed knowledge and heroes and heroines ensuring that these anonym- wisdom in the sphere of life in general that exceed ous stories cheat their final destiny, delivering a the competencies of a medical qualification, who happy ending that causes an emotional catharsis generates respect around him yet at the same in the TV audience. time is intimate enough for the sick to come to him with problems outside the health sphere. The figure of the friendly doctor was perpetu- The figure of the doctor in series ated and was the prevailing view until the end of From the very beginnings of serialized fiction, the seventies. Dr. Marcus Welby, the star of Mar- the figure of the medical professional has been cus Welby M.D., better personifies than anyone placed in the same category as the sheriff in that doctor who does his utmost for his patients,

-5- Introduction

and who we often see holding vigil at his patients’ find in series such as Breaking Bad or Dexter. In bedside. One of the central pillars of this series the medical drama, the adoption of this model of was the conflict between the protagonist and protagonist has led to the emergence and popu- Dr. Steven Kiley, since they often disagreed on larization of a model of doctor characterized by what methods to use. This friction would become a disagreeable nature and a dehumanized ap- a habitual type of conflict in medical dramas, but proach to medicine. in this case, despite one tending to adhere to the If traditional fictitious doctors were essentially letter of the medical books and the other follow- noble and altruistic, always at the service of their ing less orthodox paths, they both have the pa- patients, whose well-being they considered a pri- tient’s well-being as their central concern. They ority (reassuring manner included), the new doc- are simply heroes with different approaches with tors in fiction would be egotists who would not regard to medical practice. take their patients into account. They would con- The figure of the doctor began to mutate in sider patients an obstacle in their profession and St. Elsewhere, a series cut in a far more realistic treat them unpleasantly. Lack of orthodoxy would mode, where we find Dr. Mark Craig, a charac- be another key element. Anti-heroes in the medi- ter who puts his own interests above medicine. cal drama would be reticent to follow the hospital He abandons St. Eligius for a better-paid job and rules, would make decisions that risked the lives only returns to the center when he is promised a of others, including patients, and generally scorn pay rise and better equipment. He is portrayed as any other opinion. Their priorities would have a medical star, an easily irritated, irascible genius, more to do with the personal satisfaction of be- who has the habit of ridiculing his colleagues with ing able to solve a puzzle (the patient) than with ironic comments. His risky operations, such as curing a person who needed their help. Leading a heart transplant, make him a significant asset this trend of the medical anti-hero is the afore- to the hospital, demonstrating to viewers that en- mentioned Dr. House, who was and remains the during his personality is a fair exchange for his skill most popular of this new type of medical pro- as a doctor. The profile is similar to Dr. Gregory fessional, though the character, who premiered House, expert diagnostician in the series House on North-American television in 2004, has sev- M.D. The difference between them is that Mark eral precedents. It is worth mentioning Doctor Craig is just one character in a fictional chorus John Becker, from the series Becker, played by of other doctors who personify the view of the Ted Danson, who in 1998 was already a bad- kind-hearted doctor of earlier decades, while tempered politically incorrect doctor, or Doctor Gregory House is the protagonist in his series and Vilches, from the Spanish series Hospital Central, the absolute star of the show, personifying a new which the actor Jordi Rebellón began to play in type of doctor corresponding to the anti-hero 2000 (though in this case in a supporting role, archetype. like Dr. Mark Craig). The incursions of the North- The emergence and popularity of the anti- American cable channels into medical drama hero is not exclusive to the medical drama. have bequeathed other hospital anti-heroes, House’s success should be read within the such as the pair of surgeons in Nip/Tuck (2003), context of the transformation experienced by Nurse Jackie Peyton, in Nurse Jackie (2009), or TV series due to the ground-breaking US cable Doctor John W. Thackeray, in the historical medi- channel phenomenon, which introduced fictions cal drama The Knick (premiering in 2014). that, among many other aspects, featured mor- Whether heroes or anti-heroes, all the doc- ally complex characters. Tony Soprano, in The tors in medical dramas are characterized by their Sopranos, is the archetypal modern television huge talent and skill. They are all extraordinarily anti-hero, a subversion of the classical hero’s well-prepared and capable of resolving high-risk values yet one who manages to connect with situations and extremely complex operations. To viewers through his anxieties and weaknesses, find inefficient or irresponsible doctors, one has and a basic influence in modern anti-heroes we to abandon medical drama territory and go to

-6- Notebooks of the Esteve Foundation Nº 42

Medicine in Television Series

comedy, where series such as Scrubs, Green reality than in fiction6. Both features are resources Wing or Children’s Hospital use precisely the re- of the medical drama for imbuing greater heroism sponsible, idealized image that doctors tend to on the protagonists. No one wants to see doc- have onscreen in order to subvert it humorously. tors in fiction whose patients are not cured, or These comedies signal a break with an excess of who die on the operating table too often. Though seriousness and drama in medical series, and as these situations occur in medical dramas, they such constitute a healthy exercise of demystify- are not particularly abundant because at heart ing the figure of the doctor. they are fictions that convey, as we said above, feelings of comfort and security that are agreeable to viewers. The same occurs with medi- Relationship with the medical community cal instruments, which are more spectacular in One of the attractions of fictions set in workplaces these series, running the risk of recreating ultra- is their ability to operate as a testament to the technological hospitals that do not reflect patient reality of professions that viewers find attractive, reality. Nevertheless, it is also true that medical but of whose secrets they know few. Professions dramas exist that have made the realistic recre- such as police officer or doctor are a mystery to ation of medical equipment one of their features. viewers, who are curious to see the reality of daily So, series such as ER or House M.D. portray life for these professionals and how their work hospitals with the latest technology, whereas dynamics operate. This factor is also key in other St. Elsewhere or Nurse Jackie show the reality series that do not delve into traditional television of a lack of resources and waiting lists, taking the professions, such as the west wing of the White medical drama into the terrain of social drama. In House, enabling viewers to see how a fictitious this sense, criticism by the medical community version of a US presidential cabinet functions; or that medical drama creates false expectations in Mad Men, which shows the creative work behind viewers is valid, but only partially, since it cannot advertising spots and slogans, taking us from the be applied to all series. initial meetings with the client to the final version For medical dramas to be as realistic as pos- of the advert to be approved. In all these fictions, sible, studies often employ medical profession- viewers assume that what they are watching is als as consultants who work in close collabor faithful and based on reality. So, they construe ation with the scriptwriters. The first chapter through these series an image of the reality of of this Notebook you are reading is written by such professions. Dr. Lisa Sanders, who was consultant on the se- The medical drama is no exception to this rule ries House M.D. However, as she herself says, and wields inevitable influence in creating the col- there is an agreement between reality and fiction: lective imagination about the medical community Professional consultation, which is the medical and day-to-day hospital life. Even if such series community’s channel of influence on the fictions make a realistic approximation of the profession, representing it, is strictly adhered to only until it the mechanisms of fiction make certain license clashes with the cause of fiction. In such cases, a inevitable. Such license leads to one of the trad decision by the scriptwriter of the episode or the itional criticisms made of these series by the series showrunner will choose between the real- medical community: they can create unrealistic istic option and the one that works dramatically. expectations in viewers insofar as the medical Since the medical drama is no documentary, no instruments they are liable to find in hospital are such strict standards of realism can be enforced, concerned. The same goes for the death rate so it is logical that what works best in the script in specific situations, which tends to be higher in carries more weight than what is more realistic.

6 A 2008 report of the Organización Médica Colegial (Spanish Medical Association Organization) gave the example of cardiopulmonary resuscitation, whose results in fiction tend to be positive to a much greater degree than in real life.

-7- Introduction

The connection between medical dramas channel. Medical dramas are often crossed with and the medical community has existed since controversial moral dilemmas that enjoy diverse the genre’s origins. The series Medic, launched acceptance according to society at the time, but in 1954, was the first to pay special attention to the pressure of advertisers often acts in a censor- medical procedures. Since then, scriptwriters ing role. Despite this, throughout medical drama’s have worried about showing the work of medi- history, scriptwriters have managed to tackle cal professionals with detail and exactitude, often difficult-to-swallow medical questions, thereby relying on consultation with doctors to ensure becoming (thanks to their large audiences and they are correctly representing reality. Initially, the the public’s involvement in the fiction) a more ef- scripts were sent to medical institutions to be re- fective vehicle for influencing public opinion than viewed. So, Dr. Kildare, the most popular medical documentary programs. series of the sixties in the US, welcomed the ad- The arrival of the seventies saw a sea change vice of the American Medical Association, which in this sense, with social realism opening a breach was credited at the end of each episode. And in the traditional series genres. In the medical in the seventies, the series Marcus Welby M.D. drama, this gust of fresh air translated into fic- had members of the American Academy of Fam- tion such as M.A.S.H., whose political comment ily Physicians correcting errors in the scripts. Re- on the Vietnam War, then in progress (though the cently, independent consultants have been popu- series was set in the Korean War to camouflage lar, employed by the studio or production house. its intentions), offered a previously unconsidered They work continuously with the scriptwriters, reading of the genre. The series, created by Larry offering constant feedback and even suggesting Gelbart from the novel and film that preceded ideas for new storylines. As well as Dr. Lisa Sand- it, broadcast from 1972 to 1983, and was suc- ers on House M.D., others in this category in- ceeded by China Beach, which premiered in clude Dr. Karen Lisa Pike and Nurse Linda Klein, 1988 and this time was set in an evacuation hos- who works for the series Grey’s Anatomy. A third pital in the city of Da Nang during the Vietnam possibility is that the scriptwriters are knowledge- War. In the eighties, the medical drama of refer- able about medicine. This is notable in ER, which ence was St. Elsewhere, which was striking for Michael Crichton wrote based on his own experi- its realist approach and humble socio-economic ence as a resident doctor at Boston City Hospi- context: St. Eligius was the hospital where pa- tal, and which used scriptwriters with experience tients turned up who had been rejected by other in the profession, such as Joe Sachs, a general hospitals of greater prestige with better equip- practitioner, and Neal Baer, a pediatrician. ment. The series, created by the duo of Joshua Consultation with the medical community was Brand and John Falsey (who years later created crucial in introducing diseases unknown in fiction, another iconic medical series, Northern Expo- which is one of the most interesting characteristics sure), dealt with previously taboo themes such as of medical drama as a genre. Throughout history, breast cancer. St. Elsewhere was the first series scriptwriters in many of these series have sought to tackle AIDS, in a 1983 episode entitled “AIDS to introduce medical conditions with little or no & Comfort”. In it, the father of a family is diag- previous screen time into their storylines, thereby nosed HIV-positive, which causes a certain ner- helping to raise awareness of them. Dr. Kildare, a vousness in the hospital. He is led to reveal to his classic series, was the first to introduce epilepsy family the secret homosexual relationship he has and the problems deriving from drug addiction. with another man. St. Elsewhere’s example was It would have been the first to treat other mat- followed in 1987 by the English series Intimate ters, such as sexually transmitted infections or the Contact, which was the first series whose theme contraceptive pill, had the NBC Board of Direc- revolved exclusively around this syndrome, hav- tors not decided to reject the scripts of these epi- ing a protagonist who contracts the AIDS virus sodes written by Jack Neuman, despite the fact during a business trip when he has relations with he was supported by the then-president of the TV a prostitute.

-8- Notebooks of the Esteve Foundation Nº 42

Medicine in Television Series

The first doctor to practice euthanasia in a fic- more tools than those that the show itself aims tional series was Dr. Roxanne Turner, also from to, since series do not set out to educate viewers St. Elsewhere, though she did not do so in the but to entertain them. original series but in Homicide: Life on the Street. Actress Alfre Woodard recovered the character, Transformations of the medical drama who had abandoned St. Elsewhere in its fifth season, who we re-encounter working in a Bal- Television series are currently experiencing one of timore hospice. In the episode, entitled “Mercy”, the most interesting creative periods in their histo- from 1998, she is accused of having practiced ry. The medium has managed to achieve prestige euthanasia on several terminal patients. Notwith- that was unimaginable years ago. It is the result standing that ER was also a courageous series of changes in the television industry that have led in this regard, it took far longer before it tackled to the recognition of scriptwriters as authors and the question of assisted suicide. It was not until a the creation of series with artistic ambitions that 2004 episode, entitled “Twas the Night”, in which go beyond what was formerly considered mere Dr. Jing-Mei Chen practiced euthanasia on her entertainment. This transformation has also made own father, as he had requested in one of his few itself felt in the structure of the medical drama, lucid moments. Dr. Pratt covers for her. She per- which in the last decade has combined the re- forms the act successfully and afterwards disap- alization of a traditional formula of workplace pears, returning to China to bury her dead father programs with the exploration of new ideas that and leaving her job at the County General Hospital aim to innovate the genre. Among the most rel- for good. In the nineties, ER also covered topics evant changes are an interest in barely explored such as organ transplant or barely recognized disciplines in the medium, such as plastic sur- mental illnesses, while it also dealt with themes of gery (the Nip/Tuck series, 2003), gynecology a social nature like people trafficking or the rights (the English fiction Bodies, 2004) and sexol- of the gay community. ogy (in the series Masters of Sex, 2013), which Lastly, it is worth highlighting the value of broaden the viewpoint of the traditional medical medical dramas as educational tools. Despite the drama, often centered on general medicine. fact that they often adapt reality to the conven- Fusions with other genres have also occurred, tions of fiction, the depiction of the work done with mixed results. Making the doctor an ac- in a hospital is accurate enough to be used in tion hero by imposing a fast pace on the medi- an illustrative manner by medical students. Joe cal drama is something that has been tried sev- Sachs, the scriptwriter and producer of ER, ex- eral times with rather unpromising results. This plains it in this way: “A medication that would is the case of the 2009 North-American series take ten minutes to work [in real life] might take Trauma, focused on a group of paramedics, and 30 seconds instead. We compressed time. [...] of the 2015 British series Critical, which prom- But we learned that being accurate was impor- ised operations in real time. Neither of these were tant for more reasons than just making real and well-received, either by the critics or by viewers. responsible drama”. To viewers, medical dramas In contrast, the merging of medical drama and can also be a source of useful knowledge. In historical drama in The Knick, the Steven Soder- 2011, a woman suffered an asthma attack that bergh series that premiered in 2014, stood out as left her unconscious and her ten-year-old daugh- one of the best televised fictions in that year. Set ter practiced cardiopulmonary resuscitation as in an early-twentieth-century hospital, the series she had seen on Grey’s Anatomy, a series she revisits some of the genre’s key features, such as used to watch every week with her mother. This the figure of the anti-hero, rivalry between doc- anecdote cannot be generalized nor should one tors, ethical conflicts and episodic cases, be- deduce from it that a course in first aid may be fore a background that enables the creation of substituted for a television series, but it does tell a historical portrait depicting social conflicts like us that watching a medical drama gives viewers racism and class differences, practices such as

-9- Introduction

the sale of corpses, or surgical techniques that protagonist. The fourth chapter asks in what way to modern-day viewers are extremely rudimen- the TV series The Big Bang Theory has helped to tary. All this with a suitable taste for blood and raise awareness and popularize Asperger’s syn- arresting images that governs much of current TV drome, virtually unknown to the wider public until fiction. recently. Chapter five is an essay on drug addic- However, the most interesting element in the tion as shown in the series Breaking Bad while current transformation of the medical drama is the sixth chapter looks at how tobacco addiction that its themes are appearing in series that are is treated in a period series like Mad Men. Chap- not framed within the archetype of the genre. ter seven covers The Walking Dead as if it were Medical questions, for years contained within a medical series, treating the problem of zom- hospital series, are now appearing in series of bies as a traditional epidemic. The eighth chap- all kinds. This volume contains essays on trad ter looks at how the social problem of AIDS has itional medical series such as those we have dis- been dealt with in three very different fictions. The cussed in this introduction, but also on series that ninth and tenth chapters are devoted to the two a priori do not qualify as medical yet still contain medical disciplines most recently depicted on TV: enough elements from the genre to be analyzed firstly, an analysis of plastic surgery in Nip/Tuck here. The expansion of this content outside of and Grey’s Anatomy; then we focus on sexology the limits of hospital fiction in the last instance and the stars of Masters of Sex. Chapter eleven benefits medicine. And medicine’s presence in deals with forensic medicine, one of the most the collective imagination shaped by TV series is frequently recurring specializations on television, increasingly stronger. In any case, we believe that analyzing CSI, the series which popularized it. In a detailed analysis of certain key cases is over- the following three chapters, we explore the emo- due. This analysis we leave in the hands of the tions of three characters: Carrie’s bipolar disorder true medical professionals: the experts in each in Homeland, Olive’s depression in the mini-series of the medical disciplines who have participated Olive Kitteridge, and Rust’s path towards evil in in this book with their reflections concerning how True Detective. The final chapter is concerned the series reflect their profession. with cancer as shown in the series Polseres ver- The first chapter contains an analysis of the se- melles (Red Band Society), closing this Notebook ries House and its view of medical diagnosis. The of the Esteve Foundation. Our aim is to give medi- second postulates whether The Knick is as rigor- cal professionals a panoramic view of how their ous as it seems with a passionate journey through profession is reflected in TV series, and to give the history of surgery. The third chapter analyzes fans of the series a fresh viewpoint, one that is how a series as prestigious as The Sopranos has unexpected, interesting and enriches their favorite made psychoanalysis the key to the creation of its fictions.

-10- Notebooks of the Esteve Foundation Nº 42

House and Medical Diagnosis

Lisa Sanders

Gregory House marked a before and after within the genre of medical series. The concept of an anti-hero as hero did not merely transfer with remarkable success onto the cable TV networks, but furthermore it managed to earn the interest and respect of many health professionals. After eight seasons on the FOX network (2004–2012), 177 episodes and numerous awards, among them two Golden Globes for Hugh Laurie as Best Actor, House continues to be studied in the university sphere and in prestigious medical journals such as The Lancet.

The doctor turns his piercing blue eyes to the in this meeting the reader’s first encounter with strangely discolored middle-aged man seated the detective in A Study in Scarlet. Within minutes before him. Peering over his long, thin nose, the of his introduction to future amanuensis, Dr. John physician had the look of a predator examining Watson, Holmes announces, “You have been in prey. “Unfortunately,” he informs the man coolly, Afghanistan, I perceive.” He does not reveal his “you have a deeper problem. Your wife is having route to this deduction for several weeks and an affair.” nearly a dozen pages. When Watson begs for an “What?!?” the man exclaims, astonished by explanation, Holmes traces the observations and this strange and unsought diagnosis. The doc- thought process which makes this, like all deduc- tor casually twirls his cane as he considers his tions, seem so simple, at least in retrospect. patient, who had come to see him with skin the “Here is a gentleman of a medical type,” he color of a carrot, but complained only about a tells the eager Watson, “but with the air of a mili- pain in his back following a vigorous golf game. tary man. Clearly an army doctor, then. He has “You’re orange, you moron,” he explains irritably. just come from the tropics, for his face is dark, ”It’s one thing for you not to notice, but if your and that is not the natural tint of his skin, for his wife hasn’t picked up on the fact that her hus- wrists are fair. He has undergone hardship and band has changed color, she’s just not paying sickness as his haggard face says clearly. His left attention.” arm has been injured. He holds it in a stiff and This is the first exchange between Dr. Gregory unnatural manner. Where in the tropics could an House and a patient who’s come to him for help English army doctor have seen much hardship in the first episode of the Fox Television program, and got his arm wounded? Clearly in Afghani- House MD. And right from the start we are tipped stan.” off to the link between House and his inspiration, Arrogant, observant, intelligent; a little testy, the most famous consulting detective of all time, perhaps, but a master of deduction, who clearly Sherlock Holmes. has a flair for dramatic revelation –though per- From our initial encounter with the character, haps a little less ruthless. The parallel between House establishes himself as an observant, intelli- the two was not accidental. Show co-creator, gent, arrogant man. Prickly, even rude at times, he and executive producer David Shore, acknow is nevertheless a master of deduction, equipped ledged the intentional homage from the start: with a ruthless flair for the dramatic revelation. “Anytime one says ‘puzzle’ and ‘brilliant deduc- Those familiar with the Canon will hear echoed tion’ in the same sentence, one can’t help but

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think of the great fictional detective Sherlock tors’ Guild, the Writer’s Guild and many People’s Holmes and his trusty sidekick, Dr. Watson. And Choice Awards. indeed, Holmes –and the real-life physician that It is said that success has many fathers, and inspired him, Dr. Joseph Bell– were very much here I will make my bid for at least a small piece of inspirations for House.” that paternity, alongside Sherlock Holmes. Since Echoes of the Canon are frequent within the 2002 I have written a monthly column for the New show. The lead character’s last name, House, York Times Magazine about medical mysteries. In is a synonym of Holmes (a near homophone to my column, called Diagnosis, I tell the story of a homes). House has only one friend, James Wil- patient with mysterious symptoms who seeks son, a parallel to Dr. John Watson. House plays a doctor to discover their cause. I take readers the piano, the guitar, the harmonica; Holmes dis- into the diagnostic process and reveal the clues tracts himself with the violin. House takes Vico- and deductions that lead the doctor/detective to din, Holmes, cocaine and both occasionally inject discover the pathological processes causing the morphine or a derivative. Holmes was killed –at patient’s illness, and point the way to treatment least temporarily– by Professor James Moriarty; or even cure. House was shot and nearly killed by Jack Mo- It’s hard to remember, but at the beginning riarty. Irene Adler was, to Holmes, The Woman. of this century –before House was a household The first patient we see House save is named af- name– diagnosis was not a topic of popular dis- ter her –Rebecca Adler. House pretends to have cussion. Indeed, if you look at what was in the cancer to achieve one of his aims, a clear refer- media and entertainment world as an indicator ence to the story The Adventure of the Dying De- of what was popularly or widely known, a diag- tective where Holmes pretends to have a deadly nosis wasn’t a Holmesian process but a simple infection to catch his man. answer to the complex question presented by Holmes and Watson refer to everyone by the patient. In these shows diagnosis was merely their last names. So too do House and Wilson. a springboard to the rest of the story. In programs Holmes and House also share an unconven- from Dr. Kildare (1961–1966), to Marcus Welby tional personality and, a certain brusqueness (1969–1976) to ER (1994–2009), you may have a of manner, particularly when deep into an inter- patient who comes to the doctor or hospital with esting case. Even in their spare time similarities some type of symptoms but the focus of the dra- can be seen. Actor Hugh Laurie once likened ma occurs before or after the cause is revealed. House’s obsession with television, video games, The diagnosis itself is a one-liner that gets you and popular music to Holmes’ habit of listening from one scene to the next. to classical music or reading dull monographs For example, in ER, one of the longest run- for hours on end in order to relax his mind while ning medical series, one of the ER doctors tells pondering a case. a patient, ”I have the results from your blood ex- ams. They show you have leukemia.” No fuss, no muss. Blood is taken, a test is performed, the an- A doctor inspires a detective who inspires swer, leukemia, is revealed, and the story returns a doctor who inspires a show to what it’s really about. In these shows diagnosis House MD ran on Fox Television from 2004 to is like math. Fatigue and abnormalities found on 2012. It was one of the most popular television blood tests equal leukemia. In fact, the diagnosis shows of the decade. Indeed in 2009, it was the of this type of cancer is usually far more complex most watched television show on the planet with than that. Were there clues in the physical exam: a reported 51 million viewers. Along the way the a certain pallor in the face and eyes? An enlarged show garnered three Emmys (Best Script, Best spleen? Perhaps there was some weight loss? Directing, Best Make up), four Golden Globes None of it is important or even particularly mys (Best Actor and Best Dramatic Series, twice each) terious when the diagnosis is just one small com- and a Peabody. Plus awards from the Screen Ac- ponent of a different human drama.

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Medicine in Television Series

Actually, I think doctors liked to portray their the sitting room at 221B Baker Street but in the profession that way. The crisp precision of the exam room that inspired it. In this modern ver- science of illness and the certainty of diagnosis sion that I witnessed, the residents play the role is a counterweight to the art of dealing with the of the young Conan Doyle –physicians working complexities of human behavior and emotion. hard to learn the basics of deduction and diag The simplicity of this fictional representation of nosis, guided and corrected by the master– the process disguises the uncertainty that sur- Joseph Bell, here played by the senior doctors rounds all but the most basic diagnoses. To ac- who correct and guide and amaze when the knowledge this intrinsic lack of precision seems pupils go astray. to make doctors uncomfortable. Indeed, one might well say that House is the The first two years of medical school do noth- doctor Holmes might have been had Conan Doyle ing to contradict the impression that I –and many lived in the 21st century. It would have been im- of my fellow students– had about medicine. That possible for Holmes to be a physician at the end there is a science to it; a precision and accura- of the 19th century when first penned by Conan cy that puts it in the same class with all that we Doyle. Joseph Bell, the doctor Conan Doyle mod- learned on the way to med school and in those eled his character after, was admired for his re- first two years: chemistry, biology, anatomy, phys- markable skills as an observer, his mastery of the iology. That it is well defined, well understood –in ephemera of his time –the local geology, regional short, a science. accents, etc.– his powerful deductive reasoning That impression falls apart in the third year and his flair for the dramatic. Despite his mastery of medical school when students are taken out of of these fundamentals of diagnosis, they were vir- the classroom and put into the clinic and hospital tually useless at that time. What good were these where real medicine is practiced and the mystery skills at the end of the 19th century? The sci- of diagnosis is revealed and indeed, quietly cele ence of medicine then was rudimentary. Although brated. many diseases had been described, few were un- On my first day in my medicine clerkship I derstood. There were no tests to confirm a sus- went to the daily meeting that everyone in that pected diagnosis. Moreover, even if those basics specialty attends, called Resident Report. The had been available, there were almost no effective meeting room was dominated by a large table. treatments for anything. The doctor-trainees sat around the table. Stu- In contrast, the end of the 19th century saw dents sat in the back with the wiser and more the first blossoming of the science of forensics. experienced doctor-teachers. One resident, as The most basic tools of the detective were com- such trainees are called, describes a patient ing into wide use. The first ballistics test was who came to the hospital, sick and in need of a developed in 1835. Fingerprints were used in a diagnosis and care. The case is laid out before criminal investigation for the first time in 1892. the audience of trainees as it revealed itself to the Mug shots were first used as a means of identify- physician at the time: who the patient was; what ing those brought before the police in the 1870s he or she told the doctors; what the examination in Paris. The widespread use of the telegraph al- revealed; what the preliminary tests showed. And lowed 19th century detectives to communicate then the residents are challenged to figure out quickly with police in other districts, near and far. the diagnosis. They examine the data presented The ultimately unsolved case of Jack the Rip- before them, ask additional questions, and try per was perhaps the most famous application of to reason backward, from effect (symptoms) to the burgeoning forensic sciences at that time. In cause (disease). this investigation, teams of policemen conduct- In that first meeting, I watched in amaze- ed house to house inquiries throughout White- ment as diagnosis revealed itself to be, not a chapel, the area where the murders were com- math problem but a detective story. A Sherlock mitted and forensic material was collected and Holmes story set in its original setting –not in examined, suspects were identified, fingerprint-

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ed, photographed and interrogated and featured that obviously. You don’t have one germ framing on front pages almost everywhere. another germ because he was sleeping with the One can almost sense Conan Doyle’s frus- first germ’s wife.” tration with his own profession. Even given the Although what Fox wanted, and paid for, remarkable skills picked up from his years of ob- was a reliable procedural –the case-of-the-week serving Bell, there was virtually nothing you could kind of crime show, like CSI, like Law and Or- do to help anyone medically. So his fascination der, known and loved by the other networks– it with the process of observation and deduc- soon became clear to co-creators Attanasio and tion and the accumulation of arcane knowledge Shore, that they weren’t going to get one. In- –the fundamental tools of diagnosis– were easily stead, the show was becoming more of a serial translated into this new science. The science of drama, a program that relies on story arcs span- crime and detection. Sherlock Holmes traded his ning multiple episodes and relying heavily on the newly invented stethoscope for a deerstalker cap development of the core characters. These are and magnifying glass and the detective story was less profitable for the producing companies be- invented. cause they are less flexible in reruns. And yet, it was clear to Shore that the doctor as detective structure required more of just about everything Back to his roots to make up for the lack of a bad guy. And that the If Holmes was a detective inspired by a doctor, I doctor himself needed to embody the complex- consider myself a doctor inspired by a detective. ity normally spread out over an entire cast. “The Indeed unravelling the diagnostic mystery has more I worked on it,” Shore explained, ”the less been my obsession since that first Resident Re- able I was able to make it work as a procedural port. In my practice, and in my column in the New [and] the more the character started to come alive York Times Magazine. So, when I got a call from a for me.” That character became the guy we now Hollywood producer named Paul Attanasio who know as Gregory House. told me he was producing a show based on my Once the pilot was shot there was some con- column, I was intrigued. Would this legacy go full cern that the executives at Fox would be angry circle? It was an exciting possibility. Attanasio de- that the show wasn’t the case of the week type scribed his new show as a Law and Order type show they’d bought and paid for. “We pulled a bit ‘procedural’, where in each episode the ‘crimi- of a bait-and-switch,” Shore acknowledged. The nal’ would be an unusual disease, to be tracked team debated how to handle this when the time down and brought to justice not by police but by came to show the pilot to the Fox executives who a special team of doctors. would be making the decision about whether the The show had initially been titled Chasing show would live or die. Attanasio suggested that Zebras, a reference to the medical truism that they not tell Fox and let the show speak for itself. when doctors hear hoofbeats, they should nor- And speak it did. The show was put in the sched- mally think horses –common diseases. In this ule for the following season. show the hoofbeats would be made by zebras That’s when I got the call from Attanasio. – the rarities. The idea was immediately picked Would I work with the show to come up with the up by Fox television and funding for a pilot was medical stories that would be at the heart of each “greenlighted”. However, Attansio and his team program? Wow! I thought. My column –in Hol- –partners Katie Jacobs and David Shore– soon lywood. I could hardly speak. realized that by focusing exclusively on the dis- “Tell me more”, I asked, trying to sound casual eases, they were losing a key component of –as if calls from studio executives came as of- the drama –the human complexity. Said Shore, ten as those from nurses. It was about, Attanasio “When you are dealing with a procedural police paused briefly, then continued carefully, a doctor drama, you’ve got all these motives. You’ve got who specialized in making difficult diagnoses. A all these people hiding things. Germs don’t do doctor who was, and Attanasio paused again,

-14- Notebooks of the Esteve Foundation Nº 42

Medicine in Television Series

“irritable, arrogant, and drug-addled. A physician A tall well-built young man greeted me as I who hated patients, but loved diagnosis.” wandered into a low-slung building that looked The description triggered a brief war in my like an old warehouse. The carpets were indus- brain. That’s not how I wanted my magnificent trial and well worn. The walls were marked and a obsession to be shown –as the product of some little dingy. But Dustin (as the young man identi- jerk, some badly behaved monster. On the other fied himself) was cheerful and lively as he led me hand, showing diagnosis as a mystery to be un- past a dozen or so small offices (“This is where raveled, as detective story, and to the world well the writers work.”) into a large room that, though beyond the reach of my column, had tremendous dominated by a large table, had the casual, appeal. well-used look of a college dorm rec room. Paul Of course, based on this description, I figured greeted me and introduced me to the writers the show would be a flop. Normally I’m in the –Tommy Moran, Peter Blake, Larry Kaplow, William Goldman school of thought about Hol- Sara Cooper–, to the executive producer, David lywood –that nobody knows nothin’. But not that Shore, and medical consultant, Harvard-trained day. Hearing about a show centered on someone internist, David Foster. that seemed impossible to like (remember, this We all sat down around the oversized table was before Breaking Bad) I figured it would last a and just started talking. Several episodes of that season, maybe. first season came from that conversation. In par- Drowning the cacophony in my head, I said, ticular, I recall a discussion of how patients’ wish- as casually as I could, “why yes, I’d love to work es have to be obeyed, even if you think they are with the show”. Once I saw the pilot, though, I wrong. And that if you treat someone who does realized that I had been wrong. The show was not wish to be treated you can be charged with brilliant. The actor they’d chosen to play House, assault. That discussion was brought to life in Epi- a Brit named Hugh Laurie –who had previously sode 9 called DNR –about a jazz musician who, been known for playing the dimmer partner in a believing himself to have a terminal degenerative duo with comic actor Stephen Fry– was mesmer- illness, asks that he not be resuscitated should izing as the unlikely hero in this medical dramedy. his heart stop beating. House believes he has On the surface, House was the horror Attanasio been misdiagnosed and so, when the man’s heart described –arrogant, irritable, rude; in short, ut- stops, brings him back from the dead. Of course terly intolerable. And yet, somehow, when you, House is found right –eventually– and the musi- the viewer, looked into the eyes of actor Hugh cian lives. But not without first pressing charges. Laurie, there was a sense that there was another I met Hugh for the first time during that visit. House, a better House –a sensitive and damaged We chatted briefly and I told him that being a being lurking within that crusty outer layer. And doctor was my midlife crisis, after a successful the two of them were riveting. stint in television news. Hugh told me that his father had also become a physician as a second career. His first career was in the military and only Adventures in Hollywood when he retired, did he consider going to medi- After I signed the contract, Paul arranged for me cal school. Was he channeling his father in any to come to LA and meet the writers and actors. way in this role, I asked –too starstruck to even Driving my rental car down West Pico Boulevard I hear what that implied about his father. Laurie tried to picture who I’d meet, how this would go. smiled kindly and said his father was a very dif- My heart raced as I drove up to the guard house ferent kind of doctor. A general practitioner, he at the entrance to the studio grounds and report- saw much more bread-and-butter medicine than ed my arrival to a handsome middle-aged man House ever would. And, he added, it was odd to (a failed actor?). I was given a map and pointed think that in one season of this show he would toward the building where I was to meet writers, be making more than his father would make in producers and actors. a year. Strange, isn’t it? he added, thoughtfully.

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Bicoastal production right environment for the bacteria. However, even if it could, the infection would certainly not be Over the 8 years’ run of House MD I tried to go called bacterial vaginosis but something like bac- to Hollywood to visit the set at least once a year terial buccalosis (buccal –of or pertaining to the –but that was mostly because it was fun. Most inner walls of the cheeks). In medicine the name of my job as technical advisor was done through of a disease usually does not reflect where the email and phone calls. Writers would call with the infection came from but where it ends up. character and overlying story and I (and eventu- So, I wrote a lengthy email to Tommy explain- ally two other doctor-consultants) would try to ing this issue and suggesting several other pos- come up with a disease and a story to fit. sibilities. I got back a one-line reply from Tommy: The other part of my job was to identify inac- “Yeah. My way is funnier.” And so it was. curacies in the script. It wasn’t quite as much fun as coming up with the stories themselves, but I recognized that how medicine is seen by the pub- The Holmes-ian roots of House lic depends at least in part, on how it is shown on I recently called some of the writers from House to TV. Very early on in season 1, one of the writers ask them how they worked Sherlock Holmes into had House’s team put something in the mouth the character of House. Peter Blake, Liz Fried- of a young man having a grand mal seizure to keep him from having his airways blocked by his man, Sara Hess, Eli Attie were some of the best tongue. That never happens in medicine. We are and most productive writers for the show. Most taught from our earliest days in med school that were involved from the start of the show until the putting anything into the mouth of someone who very last days. And their answers were identical. is seizing will do more harm than good. While They were never told that House was based on the intention may be to prevent the patient from Sherlock Holmes. Never. Indeed both Blake and “swallowing his tongue” as I was told as a kid in Friedman said that until they went to work on the highschool, a spoon in the mouth can block the show Elementary, a series based on the premise patient’s airway and cause the patient to become that Sherlock Holmes is alive and working as a hypoxic. When I pointed this out, the writer im- consulting detective in contemporary New York mediately changed the scene. As a result, House City, they were unaware of how closely House was one of the few programs that correctly rep- paralleled Sherlock Holmes. Only when they re- resented the medical response to this very com- read the Canon did they see the links between mon type of seizure. the two characters. Of course, not all my advice was taken. In the Still, somehow Holmes is present in the stories second season, I got a script that contained an and in the character of House throughout all eight error that I felt needed to be corrected. Writer/ seasons. How? Clearly it didn’t originate with the producer Tommy Moran wanted to indicate some writers. Then who? It was Eli Attie who provided (umm, insert embarrassed cough here) oral-gen- the clue to help me solve this mystery. Attie came ital contact between two characters, so he had to House in the show’s fourth season, after a long the young man contract an infection that could run at the NBC hit West Wing. Attie was the writer only be transmitted that way. House diagnosed who came up with the story line that ended the the young man with bacterial vaginosis. As a series. In this 8th season’s long story arc, House’s dramatic tool, the diagnosis got the job done. best friend Wilson has metastatic thyroid cancer However, it would be an unlikely diagnosis for a and is dying. And House is about to go to pris- man. As with so many of the names of the dis- on for driving his car into his old boss/girlfriend’s eases in medicine, the location of the infection is house –through the living room wall. contained in the name –it is bacterial vaginosis It seemed so unlikely –so un-House-like– that (vagina + osis, meaning a state of disease.) This Wilson would just go quietly off to die as his friend infection cannot move to the mouth; it’s not the sat in prison. So how were they to shape this set

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Medicine in Television Series

of events into an ending, a good solid House-ian detection and, between the occasional mystery, ending? The challenge went out to the writers. tends his bees. Who can come up with the exact right story to Like Holmes, House will retire from his old fa- end the season and the show? miliar world. Since he has allowed himself to be Attie had an ingenious twist. House disap- thought dead, he’ll have to come up with a new pears just days before he is to go to prison. There identity, a new profession. But first he and Wilson is speculation that he has run away. Instead, will ride their motorcycles through the country, House has apparently been on something of a finding fun and adventures as they may, until Wil- bender –he doesn’t remember clearly but wakes son finally meets his maker and House will start up to find himself in an abandoned building in a life anew. Who knows –maybe he’ll even take up bad part of town, alone with a junkie who may beekeeping. have overdosed. Oh yeah and the building is on Hearing Eli’s story, I finally understood that fire. As House starts to pull himself together he Holmes was embedded into House through the is visited by a woman who died a couple of sea- snark and sensibility of David Shore. Shore was sons earlier. She serves as the ghost of Christ- channeling Sherlock Holmes, embedding his dis- mas past and present –confronting him with tilled essence into Gregory House. I asked Shore deeds and misdeed from the past several years. about this. He was modest in his reply. He’d al- In between bouts of what is probably a drug in- ways been a huge fan of Sherlock Holmes and duced delirium House becomes aware enough felt strangely in tune with him. Shore, who was to realize that if he doesn’t get out of the burning a lawyer before he abandoned that profession to building he will die. And he has to figure out how become a producer in Hollywood told me that to get the other guy –the overdosing junkie– out when he was representing someone he was more as well. House is able to get out, but by then the interested in seeking what he thought was the just other guy has died from his OD. House leaves his outcome than in the people he actually represent- ID next to the guy and escapes the building just ed and what they wanted. “It was a problem in the before it collapses into a fiery heap. Then he goes law. But that was what Holmes did, really. He pur- into hiding. When the body and ID are found, it is sued his own ideas of justice. He had his own very assumed to be House, giving him the chance to deep moral compass. Works a lot better on the live on but with a new identity. page or the small screen than in a court room.” Attie was thrilled when David Shore chose his “Are you then the medium by which Sherlock story to end the series. It wasn’t until after the Holmes was channeled into the heart and mind show was shot and aired and the season finally of Gregory House?” I asked. put to bed that Shore told him why he chose his “Well, I’m not Holmes; I’m not House. But ending. That story arc paralleled the final chap- those words that come out of Hugh (Laurie)’s ter in the life of Sherlock Holmes. In The Adven- mouth –I almost always agree with them. I’m ture of the Lion’s Mane, Holmes describes his writing them because I believe them. They are life at that moment. The story occurred “after my thoughts and my philosophy.” my withdrawal to my little Sussex home, when In an interview Shore expounded on that phil I had given myself up entirely to that soothing osophy –and for those who love Holmes, it has life of Nature for which I had so often yearned a familiar feel to it: “House could care less what during the long years spent amid the gloom of people feel about what he’s doing, good or bad. London.” Holmes has put away his deerstalker He could care less about whether people tried and retired to the country where he takes regular their best. The only thing that matters to him is walks through the countryside, writes his learned the result. Surprisingly, that makes him a bit of a monographs on cigar ash and other aspects of rebel in our society.”

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Notebooks of the Esteve Foundation Nº 42

The Knick and Surgical Techniques

Leire Losa

The one thing Steven Soderbergh, winner of an Oscar for Best Director in 2001 for Traffic, had not declared when he announced his withdrawal from the film world in 2013 was that he was transferring his unique aesthetic to cable TV, to join a growing list of film directors who are investing their talent in this far less interventionist medium. This is what he has done in this historical drama that takes us back to the beginnings of modern surgery in a highly unconventional way. It is set in a New York hospital in the early twentieth century, and has an even more unusual protagonist: a reputable surgeon who is addicted to cocaine, played by Clive Owen (Closer, Children of Men). Its popularity has raised visibility for HBO’s younger sibling: the action channel aimed at the male Cinemax audience.

The Manhattan Dispensary was a hospital found- inition of a surgeon is attributed, along with his ed in Harlem, New York, in 1862, which survived modus operandi: “The things relating to surgery until 1979. Throughout its history it received dif- are: the patient; the operator; the assistants; the ferent names, but was known from 1913 onward instruments; the light, where and how; how many as the Knickerbocker Hospital. This is where the things, and how; where the body, and the instru- series’ action is set, in 1900, taking as its main ments; the time; the manner; the place. The op- narrative referent the early steps of modern sur- erator is either sitting or standing, conveniently gery and efforts to improve it technically. for himself, for the person operated upon, for To understand this period, one needs to briefly the light... The nails should be neither longer nor review the history of surgical evolution from its shorter than the points of the fingers; and the sur- beginnings. Back then, surgeons were consid- geon should practice with the extremities of the ered technicians, and were not always qualified, fingers, the index-finger being usually turned to in contrast to doctors, who were the true healers. the thumb; one should practice all sorts of work However, it could be said that both disciplines with either of them... endeavoring to do them have always been closely related. well, elegantly, quickly, without trouble, neatly, According to archaeological and anthropolog- and promptly.” ical studies, the earliest surgical techniques were Galen of Pergamon was known above all for employed to treat wounds and injuries. They in- being the personal physician of Emperor Mar- cluded rudimentary cauterization, amputations cus Aurelius. Nevertheless, he was considered a and sutures, as well as cranial trepanning, dating famous traumatologist, who repaired gladiators’ back before 3000 BCE. Evidence shows that ap- wounds and described new surgical techniques, proximately 50% of individuals undergoing such such as reconstruction of a cleft lip or palate. operations survived. Interest in surgery did not take root among Hindu medicine developed surgical tech- Arabian doctors, except in the case of Al-Zah- niques as diverse as methods for repairing the rawi, the author of a compilation treatise in which auricula of ears, rudimentary reconstructive he included sections that referenced ophthalmol rhinoplasty and even cataract operations. ogical, obstetric and odontological techniques, In ancient Greece, Hippocrates was known as well as hernia repair and hemostasis (aimed at as the paradigm of a doctor, to whom the def staunching hemorrhages).

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The Middle Ages was not an especially kind clamps, which were modifications of the clamps period for surgery, given that its theocentric world that Paré used to extract bullets. Another great view conceived of disease as God’s scourge, contribution was the study of coagulation and the with healing depending on a patient’s repen- discovery of blood groups, which enabled trans- tance. This made surgeons a second-best resort fusions to be made, as can be seen in the final compared to God’s will. The founding of a guild episode of the first season of The Knick, “Crutch- of surgeons in London in 1368 is noteworthy. It field”. In the field of infection, in 1861, Semmel- aimed to separate these practitioners from bar- weiss conceived the antiseptic principle with his bers, who were the surgical precursors of doc- work Etiology, Concept and Prophylaxis of Child- tors truly specialized in surgery as such. Never- bed Fever, which would later be enlarged upon theless, the latter profession would continue their by Lister with his pulverizations of carbolic acid work of extracting teeth, blood-letting and minor (phenol) and by Bregan with the introduction of surgery until the creation of the Royal Academy steam sterilization. In 1887, Mikulicz-Radecki, es- of Surgery in 1731, when that guild was finally tablished the use of a cap, surgical mask and cot- prohibited from carrying out surgery. The second ton gloves during surgical operations, substituted episode of The Knick, “Mr. Paris Shoes”, makes from 1890 onward by rubber gloves. The fight reference to this when Thackery turns to Chris- against pain is highlighted by the arrival of ethe- tiansen and says “You are legitimizing surgery, real anesthesia through inhalation. Later, less toxic taking it out of the barber shops and into the fu- anesthetics would appear, and an important mile- ture”, in a clear allusion to its past. stone was the introduction of tracheal intubation Already in the sixteenth-century Renaissance, by Trendelenburg in 1871. So many profession- Vesalius gained fame as an anatomist, penning als from that period developed significant surgical De humani corporis fabrica. The Spaniard Miguel advances that it would be tedious to list them all. Servet, who discovered pulmonary circulation, And what can be said about the twentieth necessary for the oxygenation of the blood, was century? It is characterized by significant prog- no less well-known. All these anatomical discov- ress in diagnostic methods, such as diagnostic eries were favored by the freedom to conduct aut sonography, endoscopy, magnetic resonance, opsies, which had been prohibited by the church and so on, that enabled less aggressive surgery, and were punishable with death in the Medieval which, along with minimally invasive laparoscopic Period, should the practitioner be discovered. techniques, made it possible to reduce certain In the Modern Period, a real expansion in complications in conventional surgery while im- surgeons’ numbers occurred, bringing great proving patient recovery times. progress to the specialization. The Frenchman Ambroise Paré is considered to be the father of Characters that become blurred modern surgery. He specialized in bullet wounds, with reality designed prostheses for amputees, and made brilliant studies of Siamese twins. A curiosity from The series’ true protagonist and anti-hero, Dr. John that period was the design of a special vehicle Thackery, or Thack, becomes the head of surgical suitably equipped for the transportation of pa- staff upon Dr. Christiansen’s death. tients (the rudiments of today’s ambulance, iden- While Thackery is a brilliant surgeon, he is also tifiable in The Knick’s first episode, “Method and arrogant and ambitious, and a user of opium and Madness”, as a horse-drawn carriage). cocaíne. He is obsessed with being remembered Not till the nineteenth century did the recogni- in history for some innovative surgical procedure tion and integration of medicine and surgery take that would bear his name, to be remembered by place, with a victory over hemorrhaging, infection, future generations of surgeons for contributing to and pain –the major obstacles this science had medical advances. faced since its birth. Surgeons successfully man- There is no doubt that this character is based aged to control hemorrhaging using hemostatic on the figure of William Stewart Halsted (1852–

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Medicine in Television Series

1922), with whom he shares a great likeness. Another character who is, perhaps, based on This man belonged to the glorious epoch of a real person is Dr. Algernon Edwards. He is a surgery’s development. Thanks to his research black doctor, the top of his year, trained at Harvard on physiology and pathology applied to surgi- and in Europe, who joins Knickerbocker Hospi- cal techniques, he was considered the father tal as assistant chief surgeon, encouraged and of modern surgery, specifically North-American supported by the hospital patrons, the Rob surgery. Trained in both the United States and ertsons. He must contend with the racism that Europe under the most notable surgeons of that prevails in the hospital, both from his colleagues time, upon returning to the US he joined the staff and from patients. Like Thackery, neither is he of several hospitals, achieved fame and prestige, free from professional arrogance, which comes and gave classes in surgery. He undertook trials to the fore when he must face the daily disdain of in his pathology laboratory, perfected intestinal his colleagues. We could say that Edwards is the suture techniques and experimented with dogs alter ego of Daniel Hale Williams (1856–1931). to research the curing of wounds and thyroid Due to the racial discrimination reigning in that surgery. In 1890, he was named first surgeon in period, Afro-American citizens were banned chief of the recently inaugurated John Hopkins from entering hospitals and black doctors were University Hospital, and in 1892, he was ap- not employed as health personnel either. In firm pointed first professor of surgery at the school opposition to this situation, in 1893, he decided of medicine. to open the Providence Hospital and a nursing Halsted used cocaine as an anesthetic and school, which became the first medical center even went so far as to take it, to the point where with interracial staff in Pennsylvania. Likewise, in he had to undergo a detoxification cure in 1886, 1895, he co-founded the National Medical As- just like Dr. Thackery. sociation, a professional organization for black His assistant in the operating theater, Miss doctors as an alternative to the American Medi- Hampton, suffered from dermatitis on her hands, cal Association, which did not admit Afro-Amer- so Halsted commissioned the Good Year com- ican members. A similar activity led Dr. Edwards pany to create some rubber gloves to preserve to open his clandestine hospital in the Knick’s them. Shortly afterwards, their use was extended basement. Another of his achievements was to to surgeons’ and to their assistants’ hands to conduct the first successful open-heart surgery, protect the surgical field. We will see whether without having the benefit of transfusion or mod- in future seasons Dr. Thackery does the same, ern surgical procedures, by suturing the pericar- since at the moment no trace of gloves or surgi- dium (the membrane enclosing the heart) of a cal masks can be seen. man who had received a knife thrust in his thorax. Both the real and the fictional character were It is not so clear that other characters have innovators in several surgical techniques, notable been influenced by famous historic figures. The among which is the repair of hernias. Further- women in the series are notable for their strength more, the real person developed a technique to and individual determination: Cornelia Robert- combat breast cancer, still known today as Hal- son, daughter of the hospital’s patron, Captain sted’s operation, consisting of a radical mastec- Robertson, who heads the Knick’s social welfare tomy of the gland and pectoral muscles, along office; Nurse Lucy Elkins, who keeps both her with local and axillary ganglionic extirpation. relationship with Thackery and her addiction to The post-operative swelling of the arm after the drugs secret; and Sister Harriet, a Catholic nun aforementioned surgery is also known as Hal- who runs the orphanage affiliated with the hos- sted Syndrome. There is an amusing situation pital, who also engages in clandestine nighttime in the seventh episode, “Get the Rope”, where activity consisting of practicing abortions, which Thackery and Halsted meet face to face in the were illegal at that time. The other characters, operating theater anteroom and are introduced though not at all dispensable, have more of a by Dr. Christiansen, the former’s mentor. chorus role that gives the storyline solidity.

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Premises of the series and subplots This was such a frequent deformity that a specific “prosthesis” was invented for aesthetic reasons, The main storyline follows Dr. Thackery, a racist such as the one Abigail wears, since the damage figure, addicted to cocaine and devoted to his can extend to the total destruction of the nasal work to the point of exhaustion. It allows us to ex- pyramid. Such a stigma demanded an answer, plore one of the golden periods of surgery in terms that of covering the orifice with reconstructive rhi- of medical advances, through Nurse Elkins, with noplasty. whom he establishes a relationship, and through In India, as early as 500 BCE, a technique had his colleagues, doctors Gallinger and Chickering. been developed to repair the nasal pyramids am- The latter two, who are innovative in spirit, admire putated from thieves or enemies. It consisted of Thackery unconditionally, and accompany him constructing a frontal flap. Later, in the sixteenth through several steps of this surgical revolution. century, Gaspare Tagliacozzi described a flap that Certain details worth highlighting throughout was taken from the skin of the arm (nasobrachial) the series are the scientific advances revealed, and sutured to the nasal stump, maintaining a for example, the application of x-rays for diag- bridge with the arm, which provided nutrients and nostic purposes, and the perfecting of surgical was not cut until the flap had taken root. It is this devices and techniques. latest technique Thackery employs on the nasal In parallel, the series explores other subplots, reconstruction of his former lover. It is possible such as xenophobia formulated as humiliations that he chose this technique to avoid an obvious of a racist nature that Algernon Edwards must scar on the forehead of a beautiful woman such bear throughout the entire series, and the need as Abigail. In the nineteenth century, the German to create a secret hospital to treat black people. surgeon Karl Ferdinand von Graefe recovered The difficulty of managing a hospital that is no this technique and modified it, earning the title of charitable institution, given that its patients pay the father of modern plastic surgery. yet come along because it services a population sector consisting mainly of workers, means that its manager, Herman Barrow, must invent Ma- Inguinal hernia chiavellian schemes to correct his own errors. He The repair of defects in the abdominal wall has can think of nothing better than asking the mafia been a surgical procedure that has raised interest for help, resulting in innumerable problems. since Antiquity. Papyri from Pharaonic Egypt described the first technique for curing an inguinal Analyzing surgical techniques hernia, consisting of bilateral castration. Without being so radical, over the years the use of trusses Syphilis and rhinoplasty were recommended as a method of conserva- Syphilis is a disease caused by a bacteria called tion to avoid surgery on the hernia, which was Treponema pallidum which tends to be sexu- blighted by significant infection rates and the fail- ally transmitted, as occurs to Abigail Alford, who ure of the procedure (relapse). Once again, it was contracts it from her husband in the third epi- not until the nineteenth century that significant sode, “The Busy Flea”. Syphilis patients can go advances were announced. through several phases. In the series we identify Edwards develops a procedure in his clan- the ravages caused by benign tertiary syphilis, destine clinic to correct this pathology, which which appears from three to ten years after con- was the true work of the Italian Edoardo Bassini, tagion and is characterized by the appearances based on strengthening the posterior plane of of inflamed lesions, known as gummas, that the inguinal canal, with a low incidence of infec- evolve toward the death of the affected tissue. tion and relapse. A single case of early relapse The loss of one’s nose was one of the most com- resulting in death takes place in the third episode, mon effects of syphilis in the nineteenth century. “The Busy Flea”, due to the patient not having

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Medicine in Television Series

avoided physically strenuous activity as the doc- hernial sack is known by the eponym of Amyand’s tor ordered. This encouraging result is what Ed- hernia). Later, appendicular inflammation was wards reveals to Thackery in the sixth episode, known by the name of perityphlitis, and it was not “Start Calling Me Dad”, when Thackery discovers until 1886 that Fitz, a professor of pathological him in the basement. So a working relationship anatomy, recommended appendicular removal in begins prompted by the interest he sparks. The the case of inflammation after analyzing the post- technique is revealed in a meeting of the Met- mortem results of 257 patients suffering from this ropolitan Surgical Society in the eighth episode, affliction. “Working Late a Lot”. Halsted (once again) pro- The first extirpation is attributed to Thomas poses a certain modification concerning Bassini’s Morton, but we would have to wait for the ar- reconstruction of the internal ring, which must rival of McBurney, in 1888, who would go down be as snug as possible, and he argues: “...If we in posterity as being the first surgeon to describe could artificially produce tissues of the density the clinical manifestations of such a popular path and toughness of the fascia and tendon, the se- ology prior to its perforation, as well as the point cret of radical cure of hernia can be discovered.” of maximum abdominal hypersensitivity and the Irving L. Lichtenstein took this idea and in 1986 incision that bears his name, which is the one created a “hernioplasty free of tension”, where a employed today when it is carried out as an open polypropylene mesh is implanted on the anterior procedure, radically contributing to decreasing face of the internal oblique muscle and on the mortality, from 27% around 1900 to 0.6% today. inguinal ligament, confirming its technical sim- In episode seven, “Get the Rope”, Thackery gets plicity, early discharges and a lower incidence of into McBurney’s skin: “By drawing a line and di- relapse. Currently, hernias can be repaired using vining the midway point between the anterior-su- a laparoscope. perior iliac spine and the umbilicus, parallel to the This type of surgery constitutes one of the fibers of the external oblique, no matter what most frequent operations a surgeon must under- the size or sex of the patient... you will always take, and in all hospitals classic techniques such find the appendix.” Christensen, who is assisting as Bassini’s and Lichtenstein’s are employed. him in surgery, adds: “The Thackery Point never misses”, in clear allusion to McBurney’s point. If we had to halt our arrogant protagonist with Appendicitis a “but”, it would be to point out that the most The fourth episode, “Where’s the Dignity?”, precise location for making the incision is on the makes reference to the difficulty of locating the line described, but two thirds of the way from the cecal appendix and consequently performing an belly button, not at its mid-point. appendectomy or extirpation of the appendix, a procedure, viewers are assured, that nobody has Cocaine: between anesthetic survived to date. To our eyes this fact may seem and addiction curious, since acute appendicitis is the main cause of acute or surgical abdomen nowadays, In parallel to the development of surgery, for and therefore, a relatively common procedure. thousands of years humankind has experiment- We have to go back to the sixteenth century ed with substances for anesthetic and analgesic to find the first description of the cecal appen- purposes, never quite achieving an optimum re- dix, given by Giacomo Berengaria of Carpi, and sult, making surgery a bloody and painful proce- shortly afterwards the description of its inflamma- dure. Not until the early nineteenth century would tion during an autopsy. The first extirpation was the time be right for the progress of anesthetics, conducted in the eighteenth century by Amyand, provided by the development of sciences such who removed an inflamed appendix located in an as physiology, physics and biology, as well as inguinal hernial sack (nowadays the infrequent surgeons’ greater sensitivity to their patients’ suf- situation of an acute appendicitis contained in the fering.

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By 1831, three anesthetic agents were known pioneers in spinal anesthesia via medullary co- and employed via inhalation: nitrous oxide, ether cainization. The latter also experimented on him- and chloroform. self, and described the typical post-dural punc- The first to apply nitrous oxide for anesthetic ture headache due to the loss of spinal fluid dur- purposes was a dentist named Horace Wells, ing the anesthetic tap. This type of tap is given who inhaled the gas and extracted a tooth within the first episode of The Knick, when a patient, out feeling pain. However, a later exhibition before Mr. Gentile, previously operated on for second- his colleagues resulted in failure, since the patient ary intestinal perforation of a polytrauma, pres- began to scream and he was branded a fraud. ents septic shock due to the failure of the suture One of his disciples, Morton, experimented with made, requiring a further surgical operation. As ether both on animals and on himself, achieving the patient presents a respiratory infection, gen- a loss of consciousness through inhalation. So eral anesthesia by inhalation is not recommend- in 1846, the first surgical operation without pain able, so Thackery opts for a spinal block. (the extirpation of an injury of a vascular nature lo- At this point, it is obvious that Thackery is ad- cated in the neck) was successfully carried out by dicted to cocaine, as has been evident from the a Dr. Warren, thanks to Morton’s ether. A year lat- first episode. Cocaine, the natural alkaloid ex- er, Simpson, in England, self-experimented with tracted from coca leaves that was isolated for the chloroform with similar results, extending its use first time in 1859, has among the most powerful in Europe, while in the US, ether was preferred, stimulating effects on the central nervous system which is the gas used in the series. known, the devastating effects of which are now John Snow, from Edinburgh, was responsible well-known today. for the development of anesthetic as a specializa- Initially, it was successfully commercialized as tion when he successfully administered chloro a remedy for specific common diseases: the flu, form to Queen Victoria to ease her pain while giv- colds, toothache, etc. In this way, Mariani wine, ing birth to Leopold. Until then, it was customary with a cocaine base, was bottled and sold with- that the narcosis was administrated by the least out problems. Among this wine’s great defend- expert member of the medical team. In fact, in ers and consumers were Edison and Pope Leo the series, it is often controlled by the nurses. XIII. A glass of this wine could contain between In 1844, a needle for injecting fluids was de- 35 and 70 milligrams of cocaine, the same as a signed. A decade later, Wood sought for a way to line of cocaine. Coca cigarettes were also sold alleviate the pain caused by the neuralgia his wife for throat afflictions, and drinks with cocaine and suffered by injecting morphine. However, though alcohol, such as the well-known Coca-Cola, for morphine was not successful as an anesthetic, it headaches, melancholy and hysteria (as can be was as an analgesic. appreciated in the ninth episode, “The Golden Cocaine is the alkaloid extracted from coca Lotus”). It was in 1909 when cocaine was substi- leaves. It was in 1884 when Koller applied it for tuted by caffeine in Coca-Cola’s formula. the first time topically onto his cornea, achieving Such was the furore unleashed by cocaine anesthesia. Its use was soon extended to fields that even Sigmund Freud began to study its use such as urology and gynecology. Halsted and for treating neurasthenia, leading to an essay Hall managed a wide range of truncular blocks entitled Über Coca, in which he expounded its through injecting cocaine. The practical demon- virtues for the cure even of alcoholism and opiate strations were conducted on patients and even addiction. Only one German naturalist compared experimenting on themselves, which brought cocaine’s secondary effects to opium, but until tragic consequences due to cocaine’s highly ad- the second half of the twentieth century, cocaine dictive power, causing alterations in their social was not classified as a narcotic substance. and professional behavior. Cocaine acts by exciting the cerebral cortex James Leonard Corning (1855–1923) and and producing a state of euphoria, which in- Karl Augustus Gustav Bier (1861–1949) were creases wakefulness and physical performance

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Medicine in Television Series

because it decreases one’s feeling of tiredness. unqualified staff, such as a hospital washerwom- So Thackery employs it to avoid fatigue during an to act as a surgical nurse. his long sessions of study and surgery. Habitual It is in the seventh episode, “Get the Rope”, consumption does not create physical depen- when the cruelty with which black people are dence, but definitely psychological dependence. treated is brought to the fore. The conflict is Periods of abstinence are not common, though served with the death of a white patient who has not impossible. been attacked by a black man for having treated So we can conclude that Thackery’s inclina the latter’s wife as a prostitute. Exhorted by the tion to consume cocaine is a response to three family of the deceased, the white community factors: firstly, its ubiquity in society of the time blames the black woman for events and a ver (at the start of the ninth episode there appears itable revolt erupts in the city. on screen, “In 1900, cocaine was regularly sold in pharmacies –no prescription needed”, so Epidemiology and typhoid fever easy was it to purchase); secondly, a lack of any awareness of its negative effects combined with Ongoing mention is made through the episodes the improved performance needed for his work; of a typhoid fever epidemic affecting some of and thirdly, self-experimentation with the drug on New York’s population of a higher social stand- his own body. ing. This disease is caused by a bacteria called Salmonella typhi, whose bacilli are evacuated through the feces of asymptomatic carriers. They Racism in the hospital institution are disseminated through inadequate hygiene, Despite slavery being eliminated in the United thereby entering the water supply and foodstuffs, States in 1865, racial segregation continued as occurs in the series. The pathogens enter the to be imposed in an unofficial yet real sense organism through the gastrointestinal tract, reach throughout the nineteenth and until the mid- the bloodstream through the lymph vessels and twentieth century. In cities such as New York, cause inflammation of the lower part of the small black people were confined to specific neigh- intestine. All this generates fever, prostration and borhoods, and could not live in affluent districts. abdominal pain which can sometimes be due to Likewise, in the working sphere, black people an intestinal perforation, as happens with Cora were relegated to less-qualified positions, given Hemming in the third episode, where she re- that in most cases, they could not access uni- quires surgery to repair it. versity education. In the series, it is clear that The investigative activities of Jacob Speight, there were hospitals for whites and for blacks. an inspector from the Health Department, and Dr. Edwards joins the Knick through the media- Cornelia Robertson, following the epidemiologic tion of its patrons, the Robertsons, without hav- al clues left by the typhoid fever, lead to the as- ing previously demonstrated his worth, albeit ymptomatic carrier: Mary Mallon, a cook who insofar as Dr. Thackery has not allowed him to. spreads the disease (even though she does Taking a black doctor onto the hospital staff also not suffer from it) through her peach Melba. So meant many patients refusing to be treated by it makes those who eat it sick. We have three him, losing customers, and thereby lowering the elements here –the agent, host and environ- income of the debt-ridden hospital. Faced with ment– that comprise the epidemiological model this situation, in the hospital basement, Edwards current in the period that fitted the explanation attends several medical cases of black patients, of genesis of diseases in contrast to the simpli creating a clandestine hospital where not only city that reigned in the eighteenth century, which does he undertake surgical procedures but also explained the disease as the effect of a specific research, managing to perfect a surgical vacuum agent in an erroneous unicausal model. without the need to operate it using a crank han- This study of the distribution and determiners dle. Likewise, the situation leads him to employ of health-related states or events in specific pop-

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ulations, and its application in controlling health Zinberg and the intrascope problems, is what we currently call epidemiology. We have to wait until the eighth episode, “Work- This does not merely provide a causal explan ing Late a Lot”, to discover Dr. Levi Zinberg’s lu- ation of the disease and its distribution, but also minous intrascope, the objective of which was to emphasizes its prevention, among other, more access the body’s different cavities with the least complex objectives. invasiveness possible. This gadget was known about in 1805, in- Diagnostic instruments vented by Bozzini, who used a candle as a light source. But the invention passed unnoticed until X-rays in 1853, Desormeaux rescued it from oblivion. The German researcher, Röntgen, discovered Thirty years later, Nitze perfected it, though it was this form of radiation by chance in 1895, when still a rigid instrument, which caused patients a he detected a certain luminescence while he was lot of inconvenience. In this manner one could handling vacuum tubes. He believed this was a view a bladder through the urethral channel with- form of previously undiscovered radiation, which out the need for open surgery. he called x-rays because of their unknown na- The instrument was refined little by little ture, comparing them to an unresolved equation. throughout the twentieth century until it became Before presenting this discovery to the scientific the flexible endoscope, which enabled doctors to view the stomach. The next step was the community, he conducted several experiments, appearance of the fiberscope, made of a fiber- exposing different objects to this new radiation, optic bundle that allowed the transmission of light among them a woman’s hand, which constituted even if the end is curved, and to receive images, the first human x-ray. which was extremely useful for diagnosis, taking X-rays are a type of ionizing electromagnetic biopsies and conducting specific simple surgical radiation to which continued exposure can be procedures. The following step was miniaturizing dangerous, although, as is well-known, they have the system. a wide application in medicine. Naturally, x-rays signified a revolution in medical diagnosis, and later, the science of radiation therapy was devel- Conclusions oped. Stanley B. Burns, a New York ophthalmological Röntgen was awarded the Nobel Prize for surgeon, was always interested in history, and Physics in 1901 for this discovery, but declined to in 1975 he began to collect old photographs on patent it despite Edison suggesting this course, medical subjects. His collection now constitutes saying he was bequeathing his discovery for hu- the Burns Archive, one of the most significant pri- manity’s benefit. vate holdings of old images in the United States, Nevertheless, Edison can be attributed with with over one million historical photographs. Mid- manufacturing the first commercially available way between a circus show, due to the striking fluoroscope, shown in the fifth episode, “They nature of some of the images, and graphic docu- Capture the Heat”, in which the device is present- mentation of diagnostic means and treatments of ed to the doctors and manager of the hospital. the period, it enables us to delve into the darker Another innovation that came from the inside of life in the nineteenth and early twentieth exhaustible Edison was the roller phonograph, centuries. It has therefore been a source of docu- an invention with no medical applications, but mentation on many occasions for film-makers, which Captain Robertson shows off in a party at artists, editors, and so on, revealing a heroic age his home, recording his own voice and playing it in medicine. back later to the delight of his guests in the fourth In The Knick, Soderbergh uses Burns’ con- episode, “Where’s the Dignity?” sultation, both personally, via collaboration on

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Medicine in Television Series

the TV sets, and through the contribution of this episode, a photograph belonging to Burns’ col- graphic collection. Furthermore, he possesses lection can be seen. a collection that covers all the articles published Director Steven Soderbergh’s manner of dis- between 1880 and 1930 of magazines such as playing all this could be described as hard and Annals of Surgery and Archives of Surgery, doc- grim, comparing surgery to something akin to umenting both the huge successes of the sur- a butcher’s shop, through fairly explicit images. geons of the period, and their failures. So the first However, one should bear in mind the difficult time filming took place in the operating theater, times, for both doctors and patients, in which he had to reorder the staff sitting on the benches the action develops, when such advances as we as was done of old: in the first row sat the old and now take for granted did not exist. One should distinguished doctors, and in the next sat the as- be aware of the need to experiment for surgery sociate professors, assistants, etc. Another curi- to evolve, sometimes on the experimenters’ own ous fact is that Burns had to teach the actors flesh, at others on patients, and often on animals, how to correctly hold the different surgical instru- generally dogs. These were not easy times, and ments such as the needle drivers, perform differ- they should be paid due merit. ent suture types, and so on. Among other things, Even if it is true that the various discoveries Burns has a photo that shows a device that was occurring throughout the series are real, we can- employed to cool a person’s head, dating from not say that the date on which these events took approximately 1890. This consisted of a sort of place is likewise true. However, we understand cape surrounded by a rubber tube that acted as that this is a resource of the scriptwriters, Jack a type of coil, through which cold water was cir- Amiel and Michael Begler. Not only does it give culated. Thanks to this, the sixth episode, “Start the series greater entertainment value, but it por- Calling Me Dad”, shows this device for cooling trays the importance that this period had in order a patient’s head used on little Lillian, who has for surgery to advance to its current state of the meningitis. Furthermore, during the case of the art –a state in which we now have far more con- theft of a medical item in the series, in the second fidence than back then.

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Notebooks of the Esteve Foundation Nº 42

The Sopranos and Psychoanalysis

Oriol Estrada Rangil

For many, this program is the pioneer of television’s so-called “third golden age” (the first, heralded in by The Twilight Zone in the sixties while the second, by Hill Street Blues and St. Elsewhere, among others, in the eighties). In 1999, the inner turmoil of a New Jersey mafia boss launched a new epoch in television fiction, one which catapulted the cable chain HBO up to the highest standards of quality. Its six seasons, which ended in 2007 with five Golden Globes and 21 Emmys, also showered well-deserved recognition on the career spanning more than 30 years of its creator, David Chase.

Tony Soprano is nervous. He does not know Dr. Melfi in The Sopranos puts things into where to sit when he enters the psychiatrist’s of- perspective and shows us how this therapy has fice. “I shouldn’t be here”, he has written all over evolved. While psychologists in general have his face. It all began during a family barbecue been adopting new techniques and even aban- when he fainted in front of his two families (his doned psychoanalysis as a valid method, for blood relations and his in-laws). The diagnosis: a several years many psychiatrists have combined panic attack. His doctor and neighbor suggested psychoanalysis with pharmacological treatments, he visit a psychiatrist, Dr. Melfi, who also con- treating the patient in quite a different way to their ducts psychoanalysis. founding father’s approach. For example, they Despite fainting episodes being highly un push aside the divan and prefer to look their pa- usual in panic attacks, we have to concede to tient in the eyes, actively participating in the dis- the creators of The Sopranos that it is probably cussion. one of the TV series that has best portrayed In Dr. Melfi’s psychiatrist’s office we see the modern psychoanalysis. Proof of this is recog- famous divan, but Tony will not lie on it. Nor will nition by the American Psychoanalytic Associa- he begin to make associations of ideas while his tion, which awarded a prize to Lorraine Bracco, therapist nods occasionally (or −that recurring the actress who plays Tony’s therapist, for hav- gag– awaking with a start when the patient re- ing portrayed the most credible psychoanalyst calls their attention). In fact, one of the main prob- appearing on film or television. The truth is, until lems with the psychiatric process is that Mr. So- then the image of the psychoanalyst had barely prano is a difficult patient who does not want to changed from what it was in the early twentieth speak, one of those who thinks he is constantly century: a Sigmund Freud type smoking a pipe wasting time. An added difficulty is that, if anyone while a (hysterical) patient reclines on a divan, in his mafia environment finds out he is seeing a raving incessantly. Directors such as Woody Al- “shrink” (even worse, a “lady shrink”), it could be len have not strayed very far from that more clas- the end of his career as future capo of the New sical idea when portraying psychoanalysis on the Jersey mafia. Tony is a challenge, but Melfi will big screen. So it is understandable that her “pop insist; while she risks her professional pride, he psychoanalyst” image was so out of step with may be risking his life. the broader public (and despite her character, it One of the aims of any psychological therapy, remains so). above all psychoanalysis, is to get to the root of

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the problem, so it is worth recapping history and inhabit the tip of the iceberg, but not completely. going back to late-nineteenth-century Vienna, to The ego is the part of us that must balance the the celebrated neurologist Sigmund Freud’s con- id’s insatiable drives and the superego’s morality, sulting room, to understand what psychoanalysis and it is where internal conflicts arise that lead is based on and what it aims to do. Freud de- one to seek consultation with a psychoanalyst. fined the three aspects that comprise it as a dis- To understand it better, we can return to Tony cipline: it is a theoretical and explanatory model Soprano. We can see that his problems come of emotions; it is a research method; and, lastly, precisely from that internal struggle between the it is a form of therapy. As a theory, Freud pos- different factions of his psyche. While in reality tulated that the pillars of psychoanalysis have a they do not appear outside his mind, we accept great deal to do with sexuality, stressing the well- that in the series they become visible to viewers. known Oedipus complex, but also repression, His mafia side, that unscrupulous Tony, who is resistance and the unconscious. In fact, some violent, promiscuous and a killer, that character of the greatest criticisms, even schisms within with whom we cannot easily empathize, is the psychoanalysis are due precisely to that excess manifestation of the id, an uncontrolled id that of emphasis on the sexual question, which more neither his ego nor superego are capable of rein- than once Tony Soprano will hold up for compari- ing in. But then we have that other Tony, who is son in his sessions. sympathetic, who sometimes truly loves his wife, But there is a theoretical model of the human who worries about his kids and wants to protect psyche that did have a big impact, one crucial for them from that world dominated by the id. That understanding Freudian theory, and the case be- is where we see this character’s ego, the story fore us, the dilemmas and problems that wrack of a man who looks after his own and leads an Tony. This is the psychological structure formed apparently normal life. Yet his superego is there of the ego, the superego and the id, which act to remind him that how he earns his living is not on three different levels: the conscious, the pre- good. That is when the internal conflict arises, conscious and the unconscious. A common causing those panic attacks. Naturally, such con- metaphor that explains it more simply is the ice- flicts are fought on the unconscious plane, the berg. The largest part is hidden underwater, cor- demesne of psychoanalysis and psychoanalytic responding to the unconscious and the precon- techniques, which try to get all those submerged scious, the latter sitting above the former. Only a issues to rise to the surface. small tip, the conscious, pokes above the surface. On Sigmund Freud’s divan, the subject would Meanwhile that iceberg is divided into three parts lie back without seeing the therapist so as not to with different functions. On one side we have the feel observed, and begin speaking barely without id, completely submerged underwater, which is interruption or restrictions of any kind. It is what is our most primitive, innate, undomesticated side, known as “free association of ideas”. This is the which exists to try and satiate our most basic de- principal psychoanalytic technique to encourage sires, the so-called drives: hunger, sex or aggres- the patient to talk about anything entering their sion. Then we have the superego, which is the head, whether images, feelings, ideas, mem largest part of the iceberg and is therefore almost ories, etc. Sometimes, the therapist might sug- completely submerged, though its head remains gest a topic to the patient, or encourage them to above water. The superego represents the moral focus on their dreams, but in general they try not and ethical thought that reaches us through our to suggest anything and topics arise spontan culture, and which is in constant struggle against eously. Freud believed that this was the best way the id, like a sort of moral guardian. Finally, we of reaching the id, the unconscious, and the freer have the ego, which resembles an intermediary the associations, the better the results would be. between the real world, the demands of the id As mentioned, Dr. Melfi in The Sopranos is not and the superego. It is perhaps most similar to our a traditional psychoanalyst. In fact, probably few self-awareness, our visible face. It would mainly therapists still use free association of ideas in the

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Medicine in Television Series

purest sense. Yet traces remain in her approach, us famous books on dream interpretation and, and we often see her intervene in response to one even if the content in most of these modern of Tony’s comments in order to keep unraveling books is highly doubtful, it was Freud himself who a thread, trying to follow the associations almost in 1900 published a manual explicitly entitled The without realizing it. And had she not taken more Interpretation of Dreams (Die Traumdeutung). As of an active role, they probably would not have mentioned, the sexual question was one of the gone beyond a first session, in which the ma- pillars (not to say obsessions) in Freud’s theories, fioso wonders where the strong and silent Gary and it seems he had a tendency to interpret many Cooper types have gone. Historically, before ar- dreams from a festive or erotic viewpoint. How- riving at free association of ideas, psychoanalysts ever, the creators of The Sopranos were clear used rather more complicated methods that, that, nowadays, not everything can be linked to nowadays, are seen as quite unscientific. I am sex. In the pilot episode, Tony explains one of his referring above all to hypnosis and the cathartic dreams, where he undoes a screw and his pe- method, both of which were discarded once free nis falls off. He goes, penis in hand, to visit the association of ideas began to be used, since it mechanic to get it put back in place, but a bird was thought that the other methods were unable takes it and disappears. Beyond the supposedly to break down the barriers of the unconscious. clear sexual connection, the focus of attention is Nevertheless, within the concept of catharsis lies centered on that bird and what it came to sym- one of the theoretical and therapeutic pillars of bolize in that episode. It is a moment of revelation psychoanalysis: the idea that to cure a patient (or call it a catharsis) when Tony becomes aware, one has to recall that traumatic moment that among sobs, that one of his main problems is caused the discomfort, which that person has re- the fear of losing his family (as he lost the ducks pressed and forgotten. This is an idea which fic- that appeared at the beginning). So the episode tion has used often to create a final climax, such closes, in a similar way to how Freud believed as in Hitchcock’s Marnie, a film in which psycho- cases were closed, when the patient is able to analysis is likewise heavily present. discover what his or her problem is. And in the But if there is any place where our unconscious same manner as today’s psychology believes moves with as free a rein as most New Jersey that discovering the problem is simply the first gangsters, it is in the world of dreams. Dreams step and then one must work on it, this is where were one of the resources that the scriptwriters the series truly starts. of The Sopranos used to get directly inside Tony’s In the first season, a moment arrives when head, though they do not always make clear what Tony’s mother finds out he is seeing a psychia- each of the elements appearing signify. Why is it trist. Her first reaction, tremendously egocentric, snowing? Why can we hear that constant creak- but not necessarily erroneous, is to think that ing? What is Junior doing in that window? Why Tony is going to the psychiatrist to talk about does he kill one of his most productive workers? her, to complain about his mother. This scene Not even Tony has an explanation for the latter, perfectly illustrates some of the clichés about so he asks Dr. Melfi: “Why would I do something psychoanalysis in which the wider public believe: like that?” According to Freud, dreams represent If someone visits a mental health professional it the realization of our desires, yet it is not so sim- is because when young they had problems with ple. Despite being asleep, our conscious is still their mother. Once more, although psychology in awake, and is not willing to accept certain drives general has gone substantially further than Freud, that come from the id. So the unconscious must the influence he had on popular culture remains camouflage such desires in some way in order strong and retains its hold in the collective imagi- to overcome our censorship, thereby utilizing the nation. Part of the blame lies with one of his most terrain of metaphor and symbolism. famous (and most parodied) theories, although The idea that dreams send us “camouflaged some of the merit should go to Greek mythology messages” has been used for many years to sell itself: the Oedipus complex was described for

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the first time in his aforementioned manual The based on the mother of the series creator, David Interpretation of Dreams. Yet before discussing Chase). Nevertheless, whether due to that Ital- it, we should recap Freud’s own theory on child- ian cultural heritage of the Mamma figure, or be- hood sexual development, since he believed that cause that childhood desire postulated by Freud right from birth children seek to satisfy their libido has not been fully overcome, Tony continues to using different parts of their bodies. He divided worry about her and set her on a pedestal. He the process into five stages: the oral, anal, phal- complains that it is his wife who refuses to bring lic, latent and genital. It is the phallic stage (from her to live with them, which is supposedly what three to six years old) when the so-called Oedi- a good son should do. In fact, after talking about pus complex develops, which is defined as the how complicated his mother is, he goes to visit presence of feelings of hate and love towards her with a bunch of flowers. Some of the most the progenitors simultaneously. There can be two heated lines in Melfi’s office specifically concern aspects: a positive Oedipus complex, in which questions relating to his mother and his incapac- the child feels hatred towards the progenitor of ity to recognize that, as well as love, he also feels the same sex, and sexual attraction toward the hatred toward her. Those who do seem to have opposite sex, and a negative complex, which is taken these negative feelings toward his mother logically the inverse. In the phallic stage it is the on board are Tony’s sisters. Freud would explain male sexual organ that focuses the boy’s interest, such a rejection as them blaming his mother for and it seems that, in the case of girls, the clitoris their “castration”. In this case, they would not is also equivalent to a phallus. In this phase, the have overcome the complex or moved on to boy will feel sexual desire toward his mother, and identify with their mother. Bearing in mind Tony’s thus supposed hatred for his father (the Oedipal older sister’s mental instability, it is clear that tragedy), but by identifying with her and realiz- some trauma remains unresolved. ing that girls do not have penises, the only ex- The figure of the father, Johnny Soprano, is planation that occurs to him is that women have also worthy of analysis. Tony’s identification with been castrated. This fear of suffering the same him is clear. During the series we see flashbacks fate leads him to abandon his incestuous desires of the relationship Tony establishes with him, and identify with the father (according to Freud, midway between fear and admiration. From the this is the logical path to follow). In the case of psychoanalytic perspective, it is obvious that girls, they abandon their desire for their mother a significant problem exists in this relationship. on believing that she is guilty of their castration Overcoming the Oedipus complex is considered (through her they realize that their clitoris will not necessary for the psyche’s healthy functioning. It grow like a penis), and from that fact, so-called is supposedly at that moment when the superego “penis envy” arises, which will help them identify is born –the moral force that declares incest is with their mother again, since she has access to not good and boys should identify with the father, one, the girl’s father’s (this is known as the Electra focusing on him. As mentioned, that is exactly complex, which Freud’s old colleague, Carl Jung, what Tony does, but the problem lies in that his defined). father is the root and symbol of all his current an- And if ever there were a tempestuous story guish. His father represents all those values, all between mother and son on television, few could those attitudes that now clash with the ego and beat that of Livia and her son Tony Soprano. superego. Added to all this is the figure of Cor- Their relationship cannot be considered a clear rado, Tony’s uncle, who, in Melfi’s office, takes example of the Oedipus complex, but no doubt on a paternal role for him even before his father’s it contains elements of the above. Firstly, Tony’s death: When Dr. Melfi asks him for memories of feelings toward his mother are difficult to explain, his father, one of the first that comes to mind is since she is a sort of bitter ogre who since his playing baseball with his uncle, not his progenitor. childhood has maltreated her child (and some And is their relationship not tempestuous? As- of the toughest scenes of that childhood are sassination attempts, subterfuge to win power…

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Medicine in Television Series

Another straw on the camel’s back of Tony So- patient has about their therapist, that facilitates prano’s Oedipal family drama. the transference process. According to modern Another interesting love story occurs in Melfi’s psychoanalysts, the patient is transferring onto office itself, from the first season, even from the their therapist such feelings and experiences as pilot episode. Our protagonist shows signs of they recall, of which they speak, and addressing having noticed this psychiatrist and psychoana- that empty “vessel” which is their psychoanalyst, lyst of Italian heritage (“My mother would have sometimes identifying them with their mother loved it if you and I got together”). Dreams come or father. The patient has not fallen in love with into play again. He dreams of Melfi in bed, in the the therapist. The patient does not necessarily shower, and finally tries to kiss her in the psychia- feel that their therapist substitutes their father or trist’s office. He ends up making a confession: mother. The therapist is simply there at a moment “I love you. I’m in love with you. I’m sorry. ... when feelings arise, and therefore the therapist I dream about you. ... I think about you all the is the figure the patient addresses. As Dr. Melfi time.” To which she responds: “I know this may correctly states, this means the therapy is pro- be very hard for you to swallow, but you’re only gressing. Tony has progressed in terms of the feeling this way because we’ve made such prog- trust he has in her, so his feelings and lack of af- ress... I’ve been a broad, generic sympathetic fection also begin to come to the fore. Caution is woman to you, because that’s what this work required, however, since the psychoanalyst must calls for. You’ve made me all of the things you feel be capable of recognizing that transference (al- are missing in your wife... and in your mother.” though for this psychoanalyst it was easy), and Tony insists: “You’re makin’ me out to be some stopping it from going further. Will she manage mama’s boy. I’m a man... and you’re a woman. this? I reveal no spoilers here. End of story. And this crap about Freud and ev- Not everyone has praised Dr. Melfi: Some ery boy wanting to have sex with his mother... therapists have raised their hands in horror at that’s not gonna fly here. ... You don’t want me to certain details she reveals to Tony about her per- come back any more, fine.” But Melfi assures him sonal life, or for letting her control slip at times it is quite the opposite, that his confession is a and losing that distance and impassiveness she byproduct of his progress. Beyond the comment should maintain. Yet others have seen in all this on the Oedipus complex, and even beyond the a reflection of the therapist’s true reality, making lack of female affection that Tony seems to feel, Dr. Melfi much more believable and plausible than this falling in love is the perfect excuse to speak if the series had portrayed a textbook therapist. of some of the phenomena associated with psy- Psychoanalysts are not perfect, and neither is choanalytic therapy, in this specific case, trans- psychoanalysis. While it is probably the thera ference. peutic technique/philosophical perspective on Psychoanalytic therapy is a long process. the human psyche best-known worldwide, it is It can last years. So a personal relationship is also one of the most criticized. Currently, it does established with the therapist, somebody with not even form part of the mandatory or core con- whom profound, intense experiences and feel- tent of academic programs in Spanish psychol- ings are shared. In fact, psychoanalysts consider ogy faculties. Psychoanalysis was rejected by that in any relationship, one attributes libido to many psychologists and psychiatrists decades the other person, though they hasten to add ago (in fact, Freud himself experienced col- that the term “libido” should not be interpreted leagues such as Jung disown some of his theo- sexually. In fact, they consider it necessary for ries), and one of the main reasons is eminently the therapy to progress, since it is primordial practical. Psychoanalysis requires the patient to that the patient trusts their therapist. From their attend the consultancy for a long period of his or side, the therapist must maintain an impassive, her life, years even, and that was considered inef- distant stance (whenever possible). And it is pre- ficient. Neither was it ethical, since the patient’s cisely that distance, the sparse information the financial commitment was enormous.

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Nevertheless, some critics would blame the current approach considers that the therapeutic decline in psychoanalysis in the late fifties and work is done together. It is a process that occurs early sixties on drugs. In this, they are not refer- by listening one to the other, both what the pa- ring exclusively to hallucinogenic drugs which tient and the therapist have to say. The patient’s “expanded one’s mind” in another direction (re- subjective reality is now relevant, so both parties member that Freud felt a certain attachment to work more on how she or he sees the world, not cocaine), but to advances in pharmacological how the psychoanalyst believes things should be therapy. Here, the supposed benefit was almost (that is why Melfi is constantly asking Tony what instantaneous, making it unnecessary to spend his dreams mean to him, what his feelings are). months in therapy to begin noticing improve- Psychoanalytical psychotherapy keeps seek- ment. In fact, advances regarding the neurologi- ing those unconscious processes that affect the cal origins of certain psychopathologies led psy- patient’s life without the latter realizing, but is no chology more toward the pill than the divan. In longer exclusively related to neuroses or phobias, that period many of Freud’s theories were also but can tackle the mental problems of our age discredited, and often his own patients’ cases, (anxiety, depression, eating disorders, etc.). It is the ones leading him to formulate his theories, perhaps shallower work, therefore requiring few- were questioned. Accusations of having forced er sessions, on problems that may be less spe- memories out of his patients or interpreting what cific. Nevertheless, the divan remains and, should they told him in his own interest are criticisms that the patient so require, they can delve deeper into Freud and psychoanalysis have weathered since their psyche. the start. The Sopranos is considered one of the best But despite everything, progress in this sci- TV series of our times, one of the pioneers that ence, specifically neurobiology, seems to prove wanted to take its format beyond that of a pure Freud partially right. Perhaps not in the inter- consumer product for filling television schedules. pretation and reasoning of some of his theories, It was a series that was carefully produced in ev- but definitely in terms of certain basic ideas that ery detail, one with artistic pretensions. The care psychoanalysis proposed in its time, especially its creator took to create something special can regarding unconscious processes. So it is time be seen not merely in its manner of approach- to bring psychoanalysis up to date, in Dr. Melfi’s ing its protagonist’s psychological therapy, which office, one that has no divan, and to discover earned it the recognition of psychoanalysis pro- psychoanalytical psychotherapy. Some of the fessionals. One can truly say that the scriptwrit- practitioners of this new discipline, while recog- ers put in great effort, since four out of five of nizing that the origins and much of the method the main scriptwriters had undergone psycho- still owe a great deal to Freud, consider that cur- analysis. Many of the series viewers were simply rent psychoanalysis is as different from the origi- interested in stories about gangsters, so perhaps nal as modern physics is to Newtonian physics. they did not understand that the main story its Remember that in its early days, the patient had creators wanted to tell was of Tony Soprano, his no visual contact with the therapist, and the latter family and his therapy. However, when one ana- barely intervened in the discourse, except at spe- lyzes the series from a more psychological view- cific moments to guide the patient a little. More- point, one discovers many things that perhaps over, from that moment on, the psychoanalyst went unnoticed among so many beatings and was the maximum authority: he, rather than the killings. In the end, the part of the iceberg we can patient, decided what was important or not. The actually see is the smallest part.

-34- Notebooks of the Esteve Foundation Nº 42

The Big Bang Theory and Asperger’s Syndrome

Ramon Cererols

It is a mass phenomenon. Since its launch in 2007, this CBS comedy has not stopped winning fans and is now first among the most-viewed television fictions in the US, having nearly 20 million viewers in its eighth season. This sitcom starring two Caltech (California Institute of Technology) physicists, which makes constant references to physics’ most complex theories and principles, has garnered extraordinary success, thanks above all to its lead role. The character of Sheldon Cooper, who displays many of the characteristics associated with Asperger’s syndrome, has earned the actor Jim Parsons no less than four Emmy Awards

In the field of scientific progress it is not unusual now Klekotiv, a village that belonged to Poland, to find cases where two or more researchers but is currently in the Ukraine, in 1894), their lives make the same discovery independently and al- led them on destinies far removed from each most simultaneously, sometimes without either other. At thirty years old, Kanner emigrated to the knowing about the other’s work. Among the United States, and a few years later was com- best-known cases are those of Charles Darwin missioned to create the first children’s psychi- and Alfred Russel Wallace (biological evolution atric service in the world at the Johns Hopkins by natural selection), Isaac Newton and Gottfried Hospital, in Baltimore.1 Among the many children Wilhelm Leibniz (infinitesimal calculus), and Eli- he treated there, several captured his attention. sha Gray and Alexander Graham Bell (the tele- They displayed common symptoms differing phone). This fact shows that any great leap in from any other disorder identified to date, and the progress of science is due not just to a lucid had been classed as mental or schizophrenic mind and great dedication, but also to the prior weaknesses. They all displayed an incapacity to advances of many people who create a cultural relate to people in a normal manner, a preference environment that fosters the development of for objects, a language having no communica- new ideas. Even a figure as renowned as New- tive purpose, an excellent mechanical memory, ton, citing twelfth-century French philosopher monotonous and repetitive behavior, rejection of Bernardo de Chartres, recognized that “If I have external intrusions or loud or sudden noises, and seen further, it is by standing on the shoulders fear of change. of giants”. Kanner decided to call this syndrome “ear- One such concurrent breakthrough occurred ly infantile autism” because its fundamental or in the early 1940s. Its protagonists were the psy- pathognomonic characteristic is the child’s iso- chiatrist Leo Kanner and the pediatrician Hans lation in his own inner world. He borrowed the Asperger. Though both men were born in what term “autism” from Swiss psychiatrist Eugen was then the Austro-Hungarian Empire (Asperg- Bleuler, who had coined it in 1911 to define the er, in Vienna in 1906, and Kanner in Klekotow, behavior of schizophrenic adults, withdrawn

1 Here and below, I use a male gender to refer to both boys and girls. Nevertheless, Asperger’s syndrome is around five times more common in males than in females.

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and closed in upon themselves. In 1943, Kan- er (Autistic Psychopathy in Childhood), published ner presented his conclusions, along with a in Switzerland in 1944, a year after Kanner’s ar- detailed description of eleven case studies, in ticle. The coincidence in the naming of autism an article called “Autistic Disturbances of Affect –as “infantile autism” by Kanner and as “autistic ive Contact”, which became a classic of clinical psychopathy” by Asperger– is curious, given that psychology. as far as we know, neither knew of the other’s While Kanner was treating and studying studies.* The characteristics described were also his patients in the US, Asperger was doing the similar, even if Asperger emphasized the posi- same in his native Vienna, at whose university he tive aspects these children displayed, whom he gained a doctorate in medicine and specialized in protected in the Aktion T4 program, which aimed pediatrics. In 1932, he took over the special edu- to exterminate the Lebensunwertes Leben (“life cation section at the university children’s clinic, unworthy of being lived”, according to the term through which hundreds of children were treated. used in Nazi rhetoric). During the Second World War, he was a medical Precisely because of the geopolitical circum- officer and created a school that was destroyed stances of the time, Kanner’s and Asperger’s by shelling, in which he lost a large part of his articles suffered contrasting fortunes. While the earlier work. In 1944, he obtained the chair of pe- former’s was rapidly disseminated, Asperger’s re- diatrics at the University of Vienna, and two years mained unknown outside of certain limited, Ger- later he was also named director of the children’s man-speaking circles. So the name Asperger’s hospital at the same university, both positions he syndrome did not appear in English until 1970, would occupy until 1977. with the translation of a book by Gerhard Bosch For his qualification thesis to the chair, As- originally written in 1962 (Infantile Autism: A Clini- perger focused on a syndrome he had observed cal and Phenomenological-Anthropological In- in his consulting room in the clinic, one which vestigation Taking Language as the Guide). Yet had grabbed his attention. The children who dis- true international recognition would not arrive played this syndrome he called “the little teach- until 1981, thanks to British psychiatrist Lorna ers” since they were highly knowledgeable on a Wing. particular topic, on which they could speak for As a result of the birth in 1956 of her daughter hours. Despite this, their continuous, exclusive Susie, who had autism, Wing focused on study- concentration on the subject of their attraction, ing this disorder, and founded the National So- and their lack of interest in contact with other ciety for Autistic Children in 1962. Her husband, people made their integration into society and John Wing, likewise a psychiatrist, discovered into the standard education system difficult. Even one of Hans Asperger’s studies from 1946 and so, Asperger considered that “in some cases, translated it for his wife, who became interested these problems are compensated by a high de- in the syndrome, considering it a subcategory of gree of original thought and experience, which autism. As a result of her research, in 1981, she often led them to achieve exceptional successes published the article Asperger Syndrome: A Clini- in adult life”, and was “convinced that autistic cal Account, which in the words of Wing herself people had their place in the organization of so- “opened the Pandora’s box” to the point where cial community”. over the next two decades 900 articles were Asperger presented his work in an article enti- published on this disorder which until then was tled Die Autistischen Psychopathen im Kindesalt- practically unknown.

* Later, in his book Neurotribes: the Legacy of Autism and the Future of Neurodiversity, Steve Silberman documented the history of autism. He says that Kanner knew of Asperger’s work because one of Asperger’s assistants, Georg Frankl, had emigrated to the US and was working with Kanner. In fact, the observation and study of the first child that Kanner diagnosed with autism (Donald Triplett, who is still alive) was done by Frankl, so it is inevitable that Kan- ner knew of Asperger’s studies.

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Medicine in Television Series

Two different disorders? Autism –or as it was then called, “infantile autism”– was not considered a specific category In Wing’s aforementioned article, the author until 1978, in ICD-9, and 1980, in DSM-III (re- emphasized the common characteristics of the spectively 35 and 37 years after Kanner’s original disorders described by Kanner and Asperger, to article). Up until that moment it was considered a the extent where she asserted one should ask subgroup of schizophrenia. Fourteen years later, “whether they are varieties of the same under- the new editions of both classifications divided lying abnormality or are separate entities”. Ten autism into different categories (eight in ICD-10 in years later, in 1991, Wing came down clearly on 1992, and five in DSM-IV in 1994), one of which the side of the former, proposing the existence of was Asperger’s syndrome (according to the ICD) a continuum from Kanner’s autism to Asperger’s or disorder (according to the DSM). It would syndrome, as clinical cases showed, in which thereby acquire official recognition for the first “the same individual was typically autistic in his time, approximately half a century after publica- early years, but made progress and as a teen- tion of Asperger’s original article. This status was ager showed all characteristics of Asperger’s maintained for two decades, until in May 2013, syndrome”.2 after intense polemic, a new edition of the DSM Currently it is thought that this continuum –or (DSM-5) consolidated the autism group into a spectrum– is even broader, encompassing at one single category, autism spectrum disorder, with end the most intense cases of autism, Asperger’s three levels of seriousness according to the sup- in the middle and from there a gradual evolution port required. With this decision, Asperger’s no toward normalcy –otherwise termed “neurotyp longer has its own identity in the DSM, being sub- ical”– in which people display certain characteris- sumed into autism spectrum disorder according tics on the spectrum to such a slight degree as to to the corresponding level in each case. We must be considered simple facets of their personality. now wait and see what happens with ICD-11, In this sense, Wing considers that autistic fea- publication of which is scheduled for 2017. tures are present to a greater or lesser degree in There are five diagnostic criteria listed in all people. DSM- 5: A) persistent deficits in social communication and social interaction; B) restricted, re- Official recognition petitive patterns of behavior, interests, or activities; C) symptoms must be present during early The standard criteria for the diagnosis of men- childhood development; D) the symptoms cause tal disorders are established and updated in two clinically significant deficiencies in social and oc- publications: DSM (Diagnostic and Statistical cupational areas, or others that are important for Manual of Mental Disorders, published by the current functioning; and E) such alterations are American Psychiatric Association, currently in its not better explained by an intellectual disability 2013 DSM-5 edition) and the ICD (International or a retardation in overall development. However, Statistical Classification of Diseases and Related in almost all cases these symptoms are accom- Health Problems, maintained by the World Health panied by other varied manifestations that seem Organization, whose latest edition, ICD-10, came to indicate that the autism spectrum disorder is out in 1992). They agree in general, though with not confined to a cognitive module, but that it is certain differences. So, for example, the As- found in the brain’s general architecture. perger’s disorder defined in DSM-IV receives the Given the widespread use of the DSM for name Asperger’s syndrome in ICD-10. psychiatric diagnosis, the new criteria of DSM- 5

2 “The relationship between Asperger’s syndrome and Kanner’s autism”, in the book Autism and Asperger Syndrome, edited by Uta Frith. The same book includes the first translation into English of Asperger’s original 1944 article, undertaken by Uta Frith.

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means that patients who until then had been most frequently presents significant disparities diagnosed with Asperger’s syndrome now have between one aspect or another of an individual’s a specific degree of Autism Spectrum Disorder mental faculties. So, you might have the case of (ASD), or in some cases, no longer fall under an individual who is incapable of understanding diagnosis. Some associations, family members the double entendre in an expression and yet and patients are averse to this change, both for can construct complex scientific theories. Or one the loss of specificity it implies and the fear that who may not remember a person’s face, but can this will signify a decrease in support received, memorize thousands of digits of the number Pi. and for the negative connotations the term “au- In general, people with Asperger’s operate bet- tism” bears and loss of a certain mystique sur- ter in logical and methodical activities, and have rounding Asperger’s. difficulties with the ambiguities of social life (such Increasing knowledge of the autism spec- as interpreting ironies and double meaning, intu- trum, and improvements in diagnosis, have ition of implicit, unspoken social norms, etc.). Or, meant that the numbers of people diagnosed as the father of one child with Asperger’s com- has increased progressively in recent decades. mented: “To put it more simply, our son learns While in 1974, a prevalence of one in every 2500 social skills with the same difficulty most people (0.04%) was estimated, the most recent report learn math, and he learns math with the ease that from the US Centers for Disease Control and most people learn social skills”.5 Prevention raises this ratio to one in every 68 The progressive recognition of the compart- (1.5%), 37 times higher.3 mentalizing of mental capacities, manifested, for example, in interest in the “multiple intelligences” proposed by Howard Gardner in 1983, has Asperger’s in society spurred curiosity in the phenomenon of savant Historically, mental disorders bore a social stigma syndrome in society –people who combine def that has waned in recent years, albeit slowly. The icits in diverse cognitive areas with a capacity far Nobel Prizewinner for Economics in 2002, Ver- above the normal in a specific field. This curios- non L. Smith, who has Asperger’s, expresses it ity was picked up and emphasized by literature thus: “We’ve lost a lot of the barriers that have and film, which highlighted the extreme aspects to do with skin color and with various other char- of their natures to give them greater cinemato- acteristics. But there’s still not sufficient recogni- graphic charisma, at the cost of distancing such tion of mental diversities. And we don’t all have characters from the more common reality. to think alike to be communal and to live in a pro- The first important milestone came in 1988 ductive and satisfying world”.4 with the film Rain Man, winner of four Oscars, The traditional view on mental disorders is that in which Dustin Hoffman interpreted an autistic they form an integral part of the person, a totum savant. The character is partially inspired by Kim revolutum that completely disables the person. Peek, a person with an exceptional memory, who However, in most cases this is not so. Many could remember the contents of 8000 books and great figures in history, art or science have been a huge amount of data on the most diverse sub- so, despite –and occasionally thanks to– having jects (from a year and a half old he remembered problems in some dimension of their mind. The all the books his parents had read to him, and autism spectrum disorder is one of those that later he was able to read and memorize every

3 Community Report on Autism 2014, available at: http://www.cdc.gov/ncbddd/autism/states/comm_report_au tism_2014.pdf 4 Interview on CNBC News Channel, February 2005, available at: http://www.nbcnews.com/id/70307 31/ns/ business/t/mild-autism-has-selective-advantages/ 5 From an article by Brian G. R. Hughes on the Massachusetts Institute of Technology Alumni Association blog, available at: https://alum.mit.edu/news/WhatMatters/Archive/200308

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Medicine in Television Series

page in around ten seconds). In reality, Peek was the death of his neighbor’s dog. Boone has vast not autistic, but born with several brain defects, mathematical knowledge, but also difficulties in principally an absence of the corpus callosum relating socially. Though the blurb of early edi- (the band of white matter connecting the two tions of the book stated that he had Asperger’s hemispheres in the brain). syndrome, the author himself regretted this fact In 2001, another film also won four Oscars. and confessed he knew very little on the subject. A Beautiful Mind, based on the 1998 book of His intention was not, he says, to write a book the same name, narrates the struggle against about Asperger’s, but “a novel about difference, paranoid schizophrenia of mathematician John F. about being an outsider, about seeing the world Nash Jr., who was awarded the Nobel Prize for in a surprising and revealing way”.6 Among com- Economic Sciences in 1994 for his work on non- munities linked to the disorder, the book received cooperative game theory. In real life, Nash was highly varied criticism, from those who consider interned five different times –from five to eight it an adequate description of Asperger’s to those months each time– in psychiatric clinics. Even who believe it offers a false and stereotyped im- so, using the time between these involuntary age. It is from that date, both in film and literature, commitments he managed to develop important that works began appearing that depict protago- research. Gradually, Nash was able to learn to nists who are specifically identified with Asperg- reject his delirium intellectually, until he reached er’s. So in film, we have Mozart and the Whale a level that he himself considered acceptable at (2005), Adam (2009), Mary and Max (2009) and about 55 years old. Nevertheless, he regretted My Name Is Khan (2010), while in literature, The that this return to normalcy caused him to lose Curious Incident’s success was dwarfed by Stieg part of himself. So, in his autobiography for the Larsson’s Millennium7 trilogy, which has sold Nobel Foundation, he wrote: “So at the present more than 70 million books and been made into time I seem to be thinking rationally again in the films. Its co-star, Lisbeth Salander, is a talented IT style that is characteristic of scientists. However expert with eidetic memory and social difficulties, this is not entirely a matter of joy as if someone characteristics that the other lead, journalist Mi- returned from physical disability to good physi- kael Blomkvist, associates with Asperger’s. cal health. One aspect of this is that rationality of thought imposes a limit on a person’s concept of And series made their entrance his relation to the cosmos. For example, a non- Zoroastrian could think of Zarathustra as simply During the last quarter-century, TV series have a madman who led millions of naive followers to gone from a minor product (second-class film) to adopt a cult of ritual fire worship. But without his overtaking film in the viewer interest they gener- ‘madness’ Zarathustra would necessarily have ate. Clearly, the decisive nature of this change is been only another of the millions or billions of hu- due to a growing presence in the TV sphere of man individuals who have lived and then been talented directors, scriptwriters and actors, but forgotten”. also because the medium’s characteristics adapt In current society, film has far more media im- better to the dynamism and connectivity of to- pact than literature. So it is worth highlighting the day’s society. Add to the mix that the advances relative success of the novel The Curious Incident made by ‘series-phile’ culture coincide time-wise of the Dog in the Night-Time, by Mark Haddon, with the recognition and public dissemination of published in 2003. Its protagonist is Christo- awareness of Asperger’s, then the time is ripe for pher Boone, a fifteen-year-old who investigates the growing appearance of series with charac-

6 As published on his website in July 2009: http://www.markhaddon.com/aspergers-and-autism 7 The Girl with the Dragon Tattoo (Män som hatar kvinnor, 2005), The Girl Who Played with Fire (Flickan som lekte med elden, 2006), and The Girl Who Kicked the Hornets’ Nest (Luftslottet som sprängdes, 2007).

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ters having characteristics more or less resem- Table 1. Recent series with characters displaying char bling the disorder, or who adopt certain of its acteristics related to Asperger’s syndrome. traits. Series Character In real life, there are many cases of people Alphas Gary Bell who are difficult to diagnose with certainty, since the border between a mild disorder and a sin- Bones Bones gular personality is blurred. Such a diagnosis is Boston Legal Jerry Espenson much tougher –generally impossible– in fiction, Bron/Broen Saga Norén except for those few productions in which this point is explicitly stated in the script. So it be- Community Abed Nadir comes impossible to draw up a definitive list of Criminal Minds Spencer Reid series with characters having Asperger’s. Those CSI Gil Grissom I list in Table 1 are characters from recent series who best fit, fully or in some way, with the defini- Eureka Kevin Blake tion of the disorder. Fringe Astrid (Alternate Universe) The treatment given to the topic of Asperger’s Glee Sugar Motta in each of these series varies greatly, and in reality, the focus in many is not even suggested, Grey’s Anatomy Virginia Dixon since the only thing they aim for is not to present Hannibal Will Graham a character that fits a certain diagnostic, but House Adam one that is interesting, or funny, or encourages some kind of empathy or curiosity in viewers. House Dr. Gregory House Currently, the most popular character with most Law and Order: Wally Stevens audience success displaying traits of Asperger’s Criminal Intent syndrome is Sheldon Cooper, the theoretical Mr. Robot Elliot Anderson physicist in the series The Big Bang Theory. Below, I will analyze this character along with Orange Is the New Black Crazy Eyes examples of different approaches adopted in Parenthood Max Braverman other successful series by comparing several ReGenesis Bob Melnikov characters with Sheldon. Rose Red Annie Wheaton

Sheldon Cooper and Asperger’s Sherlock Sherlock Holmes Skins “JJ” Jones The Big Bang Theory is a sitcom that plays on the contrasting perspectives of a group of friends Temple Grandin Temple Grandin (Sheldon and Leonard, physicists; Howard, a space engineer; and Raj, an astrophysicist) and their partners (Penny, a waitress and later a sales trasts with many other traits commonly associ- agent; Amy, a neuroscientist; and Bernadette, a ated with Asperger’s syndrome. microbiologist). The series began airing in 2007 Sheldon always performs every action identi- and to date (February 2015) is in its eighth sea- cally, which tends to be peculiar. For example, son, after more than 170 episodes. The show’s whenever he calls at Penny’s door, he does so central figure is Sheldon Cooper, a theoretical using a sequence of: three knocks, “Penny!”, physicist at the California Institute of Technology, three knocks, “Penny!”, three knocks, “Penny!”. with two doctorates (the first obtained at 16) and Sheldon cannot cope with change, or hav- a master’s, with an IQ of 187, who at the age of ing anyone interrupt his routines. Every week, he five was already writing scientific articles on his strictly follows the same program of meals and notepad. This towering scientific intellect con- activities (according to him, “change is never

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Medicine in Television Series

good”). He always sits in the same spot on the build time machines”, Sheldon disagrees: “I don’t sofa (not his favorite spot, simply his spot). When, agree. Your lack of attractiveness predates your in the first episode, Penny sits in Sheldon’s spot, work on the time machine, so your failure with he complains: “Um, Penny, that’s where I sit.” Penny is due to other reasons.” And for Sheldon Penny says: “So, sit beside me.” “No, I sit there.” it is clear: “Why should I say sorry? I didn’t say “What’s the difference?” Sheldon is clear on that: anything that wasn’t true.” “What’s the difference? In the winter that seat is Sheldon needs to have everything regulated, close enough to the radiator to remain warm, and stipulated. He has a Roommate Agreement with yet not so close as to cause perspiration. In the his roommate that includes every last detail, and summer it’s directly in the path of a cross breeze when he starts a relationship with Amy he estab- created by open windows there, and there. It fac- lishes a Relationship Agreement that specifies es the television at an angle that is neither direct, factors such as the frequency and type of meet- thus discouraging conversation, nor so far wide ing, and the extent of physical contact. as to create a parallax distortion. I could go on, Sheldon is probably the most popular char- but I think I’ve made my point.” acter of all those displaying traits typical of As- Sheldon interprets what is said literally, with- perger’s. However, the viewpoint taken by The out capturing the underlying sense in the other Big Bang Theory on this theme is one motivated speaker’s words. So when he knocks on Penny’s purely by humor. In fact, the series co-creator, door in the early hours of the morning, and she, Bill Prady, claims that Sheldon’s personality is annoyed, spits out: “Do you know what time it not based on this disorder (which was not as is?”, Sheldon replies calmly: “Of course I do. My well-known when he created the character), but watch is synchronized with the Boulder atomic on computer programmers Prady used to work clock, in Colorado. It’s accurate to a tenth of a with. Furthermore, he believes it is better not to second.” assign the label of Asperger’s to Sheldon be- Sheldon does not understand the implicit rules cause, on one hand, this would limit the series’ governing social relations, and he tries to study creative possibilities, and on the other, run the them using rational logic. In episode thirteen of risk of other characters’ wisecracks about Shel- the second season, “The Friendship Algorithm”, don being taken as wisecracks about someone he wants to become friends with a colleague and with the disorder. However, whether voluntarily or visits a bookshop for a book to show him so as not, Sheldon is a caricature of Asperger’s syn- to make friends. The only one he finds is one for drome. kids, about a cockatoo that has just arrived in Was it a coincidence that the programmers the zoo. From the information obtained, Sheldon who Prady was inspired by when defining Shel- draws a flow chart for a “friendship algorithm” don had such a similar personality to a person that is detailed, logical and yet totally useless in with Asperger’s? Or rather, is there some relation real life, since, as Sheldon himself recognizes, between IT and this syndrome? Before tackling “parts of the human experience escape me”. this question, let us look at a series prior to The Society values honesty highly. So we teach Big Bang Theory, whose star is in fact a computer our children they must tell the truth. However, programmer often credited with having Asperg- children soon learn intuitively that this is not al- er’s syndrome (though in the series this is never ways the best idea. All children? No, not Shel- explicitly stated). This is The IT Crowd, a British don. He is honest, rudely and brutally so. When series that ran for four seasons (with a total of 24 Leonard, who is worried about his relationship episodes), broadcast from 2006 to 2010 (plus a with Penny, comments: “Penny thinks I’m too final episode in 2013), which follows the ups and smart for her. That’s ridiculous!”, Sheldon has no downs of a company’s IT department. As in The problem answering: “You’re right. Most of your Big Bang Theory, this is a situation comedy that work is worthless.” Or when Leonard is worried plays on the contrast between two very different that “girls like Penny don’t end up with guys who personality types, embodied by two IT support

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technicians (Roy and Moss) and the department deeper underlying the person’s cognitive archi- head (Jen), who has no idea about computers. tecture. To say that Moss is intelligent would only be The variety of symptoms observed on the partially true. Moss has huge logical and math- autism spectrum has a common denominator: ematical intelligence, which makes him suited to cerebral functioning that makes the brain better IT work, but his interpersonal intelligence is prac- suited to understanding and interacting with ob- tically nil. He can communicate perfectly with the jects than people. Objects follow specific physi- computer, but not with the people around him. cal rules and are, therefore, predictable. On the Within the department, the work that would be contrary, people act according to their own will, best suited to him would be programming in- guided by interests and objectives that are hid- stead of users’ technical support. He also lacks den from the outside and so are unpredictable. common sense and the capacity to improvise The human brain is a complex computational suitable solutions in unforeseen situations. In a mechanism that combines logical capabilities famous sketch, his office catches alight. After (reasoning, algorithmic method, conscious atten- some moments of doubt, Moss looks for the fire tion, mono-task processes, which are accurate extinguisher, places it carefully on the table and but slow) and heuristic processes (intuition, imag- starts to read the instructions: “Stand vertical- ination, automatic, multi-task processes that are ly.” Moss interprets this to mean he must stand fast but prone to error). In fact, in recent decades, straight, but when he does so, finds that the ex- some authors have suggested the existence of tinguisher is no longer in his field of vision. “Oh, two different cognitive systems in the human no! Now I can’t read it.” Faced with this difficulty, brain.9 The relative level of each of these two sys- he decides to go back to what he knows and tems varies in each individual; we all know people write an email to emergency services. who are more intuitive and others who tend to be Moss, like Sheldon, is a character whose be- more methodical. havior has been adapted to the needs of the fic- So the characteristics observed in the autism tion. Even so, what they share with Dr. Asperger’s spectrum correspond to a brain in which a sig- “little teachers”, and with the 107 million people nificant imbalance exists in favor of the former of who fall within the Autism Spectrum8, is a cer- these two systems, the one we could call logi- tain way of being and interacting with the world cal, in detriment of the latter, the heuristic sys- surrounding them, which is displayed through tem. For this reason, patients with Asperger’s are widely differing characteristics. One specific dif- more skilled in subjects governed by clearly de- ficulty in studying autism is finding the core of termined rules, and in methodical tasks or ones the disorder –that which constitutes its essence with careful attention to detail, such as informa- and raison d’être. What does it really consist of? tion technology. This would explain their more When Eugen Bleuler coined the term “autism”, populous presence in this field. which Kanner and Asperger later used to define this disorder, he took the Greek term αυτος to Sherlock, Max, Hank and Saga indicate that the individual was shut into themselves, because that was the trend he observed Below, I will look at other examples of television in the most seriously affected cases. But even in characters related with Asperger’s. The earliest the cases where this occurs, the social isolation example would be Sherlock Holmes, who was is no more than a manifestation of something initially a literary character based on the real-life

8 The statistic comes from current world population numbers, around 7250 million people, and from the aforementioned report which detects a prevalence of autism of 1.47%. 9 See, for example, the article Dual-Processing Accounts of Reasoning, Judgment, and Social Cognition, by Jonathan St. B. T. Evans, or the works of Shelly Chaiken, Seymour Epstein, Daniel Kahneman and Steven Sloman.

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Medicine in Television Series

figure of Dr. Joseph Bell (1837–1911), an eminent three episodes each in 2010, 2012 and 2014, Scottish surgeon. He was the author of several with a fourth scheduled for 2016, present the medical books (including A Manual of the Op- famous detective in the modern world, adding erations of Surgery), as well as being a pioneer new technologies to his arsenal of investigative in forensic science. He believed that every doc- resources. The image they present of Holmes re- tor should base their diagnosis on painstaking inforces his character within the autism spectrum. attention to detail, and he made every effort to Right at the start of the first episode, a morgue encourage this trait in his students. So, it is said worker paints her lips and suggests a date: “Lis- that in one of his classes he showed his students ten, I was wondering… maybe later, when you’re a vial containing a foul-smelling liquid into which finished… I was wondering if you’d like to have he dipped his finger before licking it. He then coffee?” But Sherlock does not capture the insin- indicated that the students should do likewise. uation and responds coolly: “Black, two sugars, Once they had finished, Bell repeated the opera- please. I’ll be upstairs.” Later, when she returns, tion, showing them that he had, in fact, dipped disappointed at his response, without the lipstick, one finger and licked another. Through this, he he asks her: “What happened to your lipstick?”. aimed to teach them the need to focus on ac- “It wasn’t working for me.” “Really? I thought it curate observation of the facts. Bell himself was was a big improvement. Mouth’s too small now.” extraordinarily gifted in this capacity and in draw- Though this type of behavior is repeated ing conclusions from the smallest details. So his throughout the series, the only time when such a help was often required by the police in their in- diagnosis is explicitly proposed is in the second vestigations. (Some claim that he even assisted episode of the second season, when Inspector in the case of “Jack the Ripper”, but there is no Lestrade, annoyed at Sherlock’s behavior, com- evidence of this.) plains to Watson that it “must be due to his char- One of Bell’s students in 1877, and later his acter…”, and Watson confirms: “His Asperger’s?” assistant, was Arthur Conan Doyle, then a medi- The series in which Asperger’s is explicitly cal student at Edinburgh University, from where dealt with is Parenthood, in which two charac- he would graduate four years later. Already, dur- ters have the disorder. The action is set with the ing his studies, Doyle had begun to write works following scene: While eating in a restaurant, of fiction, but those that made him universally Adam receives a call from his wife Kristina, who famous were the stories starring the detective, in a worried voice asks him to meet her. When Sherlock Holmes. Doyle admitted to Bell himself he arrives, Adam sees the concern on her face. that he had created the character based on Bell’s “What’s going on?”. “Um, I heard from the edu- personality, a combination of his acute concen- cational therapist. And she said that she has tration when at work, his passion for detail and some concerns about Max. She feels that Max his capacity for logical reasoning. And it may be has some learning differences.” Well, that isn’t so supposed that, although he did not include them serious, thinks Adam. They are both concerned in the list, other of Holmes’s less praiseworthy about their son’s strange behavior, but if it is just characteristics, such as his lack of empathy, a an educational problem, it can be solved. “Okay, certain arrogance, and the anxiety he attempted listen, I’ve given this some thought, I wanna to counter with his addiction, also originated with contact the school, get Max a tutor to help him Bell. All this encourages speculation on whether through this rough period.” But Kristina knows it Holmes’s character, and consequently Bell’s, cor- is more than this. “Honey, she wasn’t just talk- responds to the profile of Asperger’s syndrome. If ing about... academics. ... Honey, she thinks that so, Doyle was describing a case almost 60 years he may have...” Her voice fails her. “She thinks prior to Hans Asperger publishing his article. that he may have Asperger’s.” Adam is surprised Among the many adaptations of the character and incredulous. “Asperger’s? Like autism? ... for the screen (both the wide and the small), the I’ve seen autistic kids. ... The Lessings’ kid with BBC series Sherlock, with three brief seasons of the hand flapping...” However, after the interview,

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Kristina is better informed. “It’s high-functioning Katims, has a son with this disorder, which led autism. A lot of people with Asperger’s ... live very him to research the subject thoroughly and to try productive lives, Adam. ... [The therapist] said to represent it on-screen in the most exacting and that if we get him the right tools to learn…” direct way possible. Virtually none of the series I Parenthood is a series by the channel NBC included in Table 1 specify that the character’s which narrates the difficulties of three generations characteristics are due to Asperger’s syndrome, of the Braverman family: Zeek and Camille are the or at most, this is indirectly insinuated at some grandparents, who have four kids, Adam, Sarah, point. Yet in Parenthood, the term “Asperger’s” is Crosby and Julia, some of whom have partners, pronounced 125 times (in addition to “autism” or and kids. The fragment described, focusing on “autistic” 23 times, and “spectrum” another eight Adam and his wife Kristina, is in the series’ first times, used in the sense of autism spectrum).11 In episode, but could come from the real life of any of fact, after the second episode of the first season the many families who have undergone similar sit- was aired, a curious event occurred. Though the uations when they discover their child suffers from initial episode had mentioned Asperger’s (in the a disorder that they may never have heard about. fragment I copied above), the second episode Parenthood is the series that describes Asperg- emphasized it with greater intensity (13 times), so er’s syndrome most explicitly and rigorously. The it seems to have lodged more firmly in viewers’ scripts are assessed by experts on the subject, perception. Curiosity concerning a medical con- and every two episodes the director, executive cept that people had not heard of meant that the producer and the actor playing Max meet with an morning after the broadcast, the most searched- Asperger’s specialist to ensure that the perform for expression on Google was “Asperger’s dis- ance mirrors the disorder. A singular feature of ease”. Parenthood that reveals its involvement with the The most idiosyncratic characteristics of As- disorder is that the series runs a blog10 called The perger’s –as well as its repercussions for the experts speak, where doctors and researchers individuals themselves and those around them comment on episodes and offer families advice. (family, social network)– were being projected Max presents the social deficits and adher- from the very first episodes. Just two minutes ence to routines that are the diagnostic clues to into the start of the series we saw the grandfather Asperger’s. He is also hypersensitive (to sound (Zeek) expressing his concern to Max’s father and touch), is unable to understand facial expres- (Adam) because the child refused to play on sions or implicit social rules, and suffers nervous the baseball team, preferring to stay home and crises or tantrums when anything alters his plans. play alone. Adam, who knows that Max dislikes However, one should not think that all children baseball (because of his lack of skill at sports and with Asperger’s are like Max, since each case can because he feels uncomfortable in groups), tries be manifested in differentiated aspects and to to justify this, saying that the grandfather’s insis- varying degrees. The way in which each person tence on this score makes Max “a little nervous”, reacts to their difficulties is also different. In reality, adding: “Max is a sensitive kid, that’s all.” Zeek’s two people with Asperger’s can be as different abrupt answer expresses an entire viewpoint to each other as two neurotypical people might –unfortunately, one that is pervasive– of dealing be, though this does not stop an expert profes- with human diversity: “Well, you were sensitive sional from detecting the disorder after observing too. I cured you.” These few words allow us to a child’s behavior for a while. reflect on certain therapeutic methods that aim The highly realistic treatment of Asperger’s in more to adjust children’s behavior to the social Parenthood is because the series creator, Jason standard than to help them develop their specific

10 http://www.nbc.com/parenthood/blog/the-experts-speak 11 Not counting the final episode, which had not been aired at the time of writing this paragraph.

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Medicine in Television Series

capacities and live fulfilling lives.12 And in case the Dr. Pelikan, gives advice to viewers who may find idea, given its briefness, goes unnoticed by view- themselves in this situation: “You will help to un- ers, the next scene shows Max’s mother (Kris- cover Max’s gifts. You figure out how he learns. tina) and sister (Haddie) wondering why baseball You get as much support for Max as possible. is so important. Kristina’s answer is clear: “Well, Quite honestly, the research clearly shows the because men feel the need to express their love greatest barometer of success for children with through hitting balls, slapping butts, and discuss- Asperger’s is their parents’ involvement.” ing meaningless statistics. And I think your father One aspect that concerns parents when they thinks that if Max doesn’t do these things he’s receive such a diagnosis about their child and still gonna grow up to be sad and alone.” Haddie do not know much about Asperger’s is the fact concludes: “Well, that’s absurd.” that it is not temporary, but a characteristic that After the therapist indicates to them that Max will accompany their child all his life. Adam ex- may have Asperger’s, Adam and Kristina begin presses it like that when they return home after to do research and get in contact with the par- their visit to Dr. Pelikan: “I can deal with anything. ents of another kid with Asperger’s, who recom- I... I can deal with disease, with illness, with a mends they follow a gluten-free diet: “No wheat. broken bone. Give me something I can fix. But No sugar. No chemicals. Casein-free too.” Kris- I just... I don’t know how to deal with this. This is tina asks: “What’s casein?” A quick comeback: for life.” True, autism spectrum disorder is for life, “I don’t know.” And immediately: “We have a nu- but that does not mean that it always affects the tritionist that you are gonna love.” (This is a nod person in the same way as it does during the early at the “cures” that are sometimes proposed in years of development –at least not in most cases, certain circles, arising from the impotence that especially if help is given early. Even without this some parents feel at not finding a solution to their help, many people who were children when the child’s problem.) However, the next piece of ad- disorder was still unknown are now adults lead- vice is useful: “You’re going to need a behavioral ing apparently normal lives. therapist. They say Dr. Pelikan is the best. ... [but] Children with Asperger’s –without abandon- no one gets in to see Pelikan. He’s an elusive ass. ing the essence of what makes them like that He’s like the Bob Dylan of autism.” and constitutes the way they are and see the Luckily, a chance situation gets them an early world– can learn to integrate and relate with their appointment with the doctor. After the visit, environment, and to become capable of contrib- Pelikan tells them his diagnosis: “Max is very high uting their special personal capabilities toward functioning. But I do find that Max’s behaviors society’s progress (as many of them have done). are consistent with an Asperger’s diagnosis.” The Parenthood reflected this throughout the series, confirmation falls like a piano on the parents, who showing Max’s progressive evolution in self- were hoping it might be something temporary: control, his social relations and, in the sixth and “So how long is this going to take then?” The re- last season, his first romantic crush on Dylan, a ality is quite different: “Unfortunately, there is no classmate suffering from attention deficit hyper- cure for Asperger’s.” It is a syndrome that he will activity disorder. always have. Kristina: “What... what are we sup- Yet furthermore, to complete the life perspec- posed to do for him?” Then the series, through tive of the person with Asperger’s, from the fourth

12 “It’s important to value our children as individuals, even if they are not the children we expected them to be. The tragedy of our society is the rush to services that are geared specifically at inculcating conformity as opposed to helping the child develop into the unique adult they will eventually become. We easily forget that the goal isn’t a well-behaved child but a happy, successful and independent adult. An intervention is deemed ‘successful’ when the child appears to behave just like all of the other kids, but little attention is paid to the long term goal or the rami- fications of forcing square pegs into round holes.” Corin Barsily Goodwin and Mika Gustavson, 2011. Available at: http://www.thinkingautismguide.com/2011/02/asd-and-giftedness-twice-exceptionality.html

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season onward, the series incorporated an adult chance. For them all, the moment means finding character: Hank, a man with few social skills. He the explanation for their past and perhaps be- is a professional photographer who has a studio ing able to make peace with themselves. where Max’s family goes to get a group portrait Parenthood is the series that deals with As- done. Hank is looking for an assistant, and Sarah, perger’s syndrome in the most explicit manner, who is Adam’s sister and Max’s aunt, applies for closest to the situation of many families who the job. Initially, Hank rejects her because of her have similar experiences. I will end this review lack of technical knowledge, but he soon realizes with another quite different series. This one never that Sarah has the skills for dealing with custom- even names the disorder, but I consider it highly ers that he lacks and he hires her: “Turns out the instructive, since both through its plot idea and people at the shoot, they liked you. They, um, in the relationship it establishes between the made a big stink about it. So it turns out you’re two leading characters, and even symbolically good at the schmooze. And I hate talking to cli- through the setting in which it takes place, and ents. Truly, I hate it. I get a little sick in my stomach the series name itself, it sends a message that sometimes. Yeah, so that’s why I was gonna call is valid not just for the case of Asperger’s syn- you. You’re not as awful as I originally thought.” drome, but for human diversity of any kind. The relationship between Hank and Sarah, ini- Bron/Broen is a series co-produced by Swed- tially a professional one and later romantic, puts ish and Danish public television along with the Hank and Max in contact, who, because they German channel ZDF. To date, two seasons have share similar character traits, become friends. been produced, with a total of 20 episodes.13 The One day Max gets angry at Hank because he had bilingual title means “bridge” (Bron in Swedish, promised to help him with some photos and, due Broen in Danish) and refers to Öresund (or Øre- to work reasons, Hank could not. Max throws a sund) Bridge, an eight-kilometer-long architectural tantrum, yells at Hank that he is a liar, and runs marvel that, along with a four-kilometer tunnel, home to shut himself in his room. A few days links Sweden and Denmark. The bridge has a later, Max’s father appears at Hank’s studio to constant presence in the series, since it is on its apologize for this behavior. He explains that Max central point, just on the line marking the border has a disorder called Asperger’s syndrome and between both countries, that a body appears. The leaves him a book on the subject so that he can death must be investigated jointly by the police of understand what happened. Sweden and Denmark, countries separated by a Minutes later we see Hank at night, reading certain social and cultural distance. From that mo- the book with growing excitement, turning pages ment onward, the characters are constantly forced nervously and highlighting sections. He runs to to cross the bridge, both in a real sense, to pursue Sarah’s house. Seeing him so troubled, she asks: their investigation, and figuratively, by learning to “What’s this book? What’s up?” Hank answers ex- understand and accept their differences. citedly: “I was reading this book for Max. And then In charge of the Danish side of the investiga- all of a sudden, I’m not reading about the kid any- tion is detective Martin Rohde, a man whose ap- more. I’m reading about me! This book is describ- parently calm and ample figure brings to mind a ing me. I’m seeing my life. My life. I can see every- polar bear. Yet he pursues his work with a pas- thing, absolutely everything. That is why stuff hap- sion, to the extreme of taking justice into his own pens to me. I’m like him. I’m like Max.” How many hands. In contrast, on the Swedish side, we have adults in recent years have experienced that mo- detective Saga Norén: a meticulous person, hard, ment! Some, when their children have been diag- cold and humorless, who follows the rules scru- nosed. Others, like Hank, when reading a book by pulously, is incapable of lying, and brilliant in her

13 Until August 2015. There has also been a US remake, The Bridge, that takes place on the border between the US and Mexico, and another Franco-British version, The Tunnel, centered on the Eurotunnel.

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Medicine in Television Series

work, but with no skill at social niceties. No doubt accept Saga’s way of being, and becomes her the scriptwriters were guided by Asperger’s syn- confidante and assessor in social questions, as drome when defining her character, though at no through her he acquires a previously unknown time during the series is explicit reference made view of the world. For her part, Saga learns to to it.14 see Martin as the closest she has ever had to a To a certain extent, Saga and Martin are the friend, something she confesses at the end of the antithesis of each other, and so their initial con- last episode aired, when she discovers he has tact causes mutual perplexity, incomprehension committed a punishable offense: “I have ana- and some rejection. Nevertheless, little by little, lyzed your motives and I have concluded… you they establish a bond, a form of male-female are my only friend.” friendship unrelated to sex or even external No doubt it is the lesson we should take away shows of affection. I would venture to say it is from the series: acceptance of human diversity in such a relationship as might exist between an all its variety, and collaboration to overcome any understanding father and a daughter who is ex- differences (mental, nationality, culture, etc.) so periencing certain difficulties. Martin manages to that we can all build a better world.

14 I would note the coincidence (or not) that means that in the sample of characters displaying Asperger’s I have chosen, there are five males (Max, Hank, Sheldon, Moss and Sherlock) and one woman (Saga). In other words, the same ratio as in real life, according to the aforementioned CDC report.

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Notebooks of the Esteve Foundation Nº 42

Breaking Bad and Methamphetamine Addiction

Patricia Robledo

If any series has garnered close to unanimous approval among both critics and viewers, it is without a doubt the story told over five seasons about a common chemistry teacher’s descent into hell, a man who becomes the largest methamphetamine distributor in New Mexico. Thanks to Bryan Cranston’s outstanding acting, the character of Walter White has become a TV icon. Having won sixteen Emmys, the series, along with Mad Men, has turned cable channel AMC into a serious competitor with the all-powerful HBO. After the show’s 2013 finale, its creator Vince Gilligan presented Better Call Saul, based on a secondary character from the original series.

The main theme of the series Breaking Bad is accidents, convulsions, agitation and hyperther- synthesis and distribution of methamphetamine mia, and they are mostly the cause of abuse and in a small US town on the border with Mexico. addiction to this substance as well.1 The subject In a highly realistic way, the series depicts how of addiction presented in the series agrees with the methamphetamine market can be a lucrative scientific evidence and clearly shows the addict business, since there is huge demand for this ive process. So, according to one of the most product and because its synthesis is inexpensive, influential theories, addiction to abusive drugs is its chemical precursors being relatively cheap established by the interaction of a vulnerable indi- and easy to purchase legally. Meanwhile, the vidual with the neurobiological changes the drug series deals with two crucial problems linked to causes, which depend on the amount of expos methamphetamine trafficking. The first is the vio- ure. Addiction is a recurring illness that consists lence associated with the war for absolute market of different phases, including the intensification of control, and the second, abusive consumption of consumption or escalation, increase in the need this substance and its negative consequences. to consume, loss of control and relapse into us- On the latter point, the series faithfully shows how ing even after prolonged abstinence.2 methamphetamine is a highly addictive abusive drug which is mainly consumed for its long-lasting The three faces of methamphetamine euphoria-inducing properties. It produces its psy- synthesis and distribution chostimulant effects by increasing monoamine extracellular concentrations in the brain. The fast, Jesse Pinkman is a young high school dropout constant increase of noradrenaline is the cause with substance abuse problems, who is rejected of its known “toxic syndrome”, characterized by by his family because he cannot get off drugs tachycardia, hypertension, mydriasis, diaphoresis and back into society. and psychomotor agitation. Prolonged release of Though he failed chemistry at high school, he central monoamines and activation of the sym- has the formula for preparing methamphetamine pathetic nervous system produce most of the –or crystal meth as it is called on the streets– acute neurological complications associated with which he prepares in a secret lab in his garage. methamphetamine use, such as cerebrovascular Jesse’s formula, which is based on chemically re-

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ducing pseudoephedrine, is the method used in This method of methamphetamine synthesis is real life. Jesse’s friends, Badger and Skinny Pete, shown in episode “Seven Thirty-Seven” of the se- are also drug addicts and undertake to source ries, the first in the second season. Walter’s broth- the raw material by buying the nasal deconges- er-in-law, who works for the US Drug Enforcement tant Sudafed, which contains pseudoephedrine, Administration (DEA), is surprised to see the video from different pharmacies. Once the pseudo- of a theft of methylamine and comments: “P2P ephedrine is extracted, it is reduced using iodine –they’re cooking old school biker meth”. His com- and red phosphorus to form methamphetamine ment refers to the fact that during the 1970s and or N-methylamphetamine. Jesse’s methamphet- early 1980s, methamphetamine was produced amine distribution is small-scale, using his drug- by this method and distributed by the Hell’s An- addict friends as pushers, who mainly sell the gels motorcycle club in northern California, until drug locally. According to the Spanish National it stopped being used due to the classification of Plan on Drugs, in Spain, methamphetamine is P2P on the list of controlled substances.3 By the known by the names speed, meth, chalk, ice or mid-1990s, most P2P labs had been substitut crystal, and is consumed by smoking. It can also ed by pseudoephedrine/ephedrine-based labs.3 be taken orally, inhaled or injected, which deter- However, the law relating to methamphetamine mines the type and magnitude of the effects it precursors in the years 1993, 1995 and 2005 in produces. the US meant that both ephedrine and pseudo- Walter White is a highly intelligent man whose ephedrine also became controlled substances.4 creative aspirations in the chemistry field are This fact contributed to a decrease in the market foiled, so he ends up as a high school chemis- and the recovery of the old P2P method of synthe- try teacher. The situation makes him deeply bitter sizing the drug. So, in late 2010, 69% of American because of the lack of incentive and his financial and Mexican samples examined showed that they problems. Moreover, he has serious health prob- were produced using the P2P method.4 lems involving costly treatment. By chance, Wal- Some discrepancies between the TV fiction ter finds out that Jesse, a former student of his, and reality have to do with the incredible purity is synthesizing methamphetamine under danger- that the methamphetamine prepared by Walter ous conditions. He decides to suggest a more seems to have. So one feature of Walter’s meth- efficient manner of synthesizing a large quantity amphetamine is its blue color, which in strict of extremely pure methamphetamine. His idea chemical terms does not agree with its claim to is to earn a lot of money so that his family can be 99% pure, given that this color is a sign of im- live comfortably after his death from lung cancer. purity. Another discrepancy with real life is related Walter is a disciplined, well-organized man, with to the fact that the ultra-pure methamphetamine an astonishing ability in chemistry, traits which that Walter prepares is found on the streets in will serve him well to improve the purity of the equal purity, which does not normally happen meth and set up a lab in a van that can travel because distributors tend to adulterate the drug out to desert regions to effectively elude the city’s with other compounds to increase its volume and police controls. In the series, Walter stops using earn more profit. the pseudoephedrine-based method because of Walter also changes the means of metham- the difficulty of acquiring large quantities of this phetamine distribution to make the business more precursor. Instead, he suggests using a meth- lucrative, associating with an extremely danger- amphetamine preparation method known as ous Latin distribution network. These two means “reductive animation” or “2P2 method”, which of methamphetamine distribution are faithfully re- consists of reducing phenyl-2-propanone (P2P) flected in the series. The first, on a small scale, using phenylacetone and methylamine. Methyl- carried out locally by drug addicts, and the other amine is used in industry, but it is a substance on a large scale, controlled by mafia. that is tightly controlled by the anti-drug law en- Gustavo Fring is a Latin drug trafficker who forcement agencies. controls the business in the American west in an

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organized way. He passes completely under the by dysphoria, restlessness and anxiety. Further- radar because he has an infallible money laun- more, he displays bruxism (clenching or grinding dering system. Walter and Jesse are associated his teeth for no reason) and the shakes. In the with him to synthesize big amounts of meth in a series, Jesse is the typical meth addict who little large secret lab that Fring sets up for them in the by little loses control of his life and the support of city where they live. This fact is similar to the real- his parents due to his addiction. So, in “Down”, ity of the so-called super-labs, that are known in the fourth episode in the second season, we see Mexico and which probably also existed in the US how Jesse becomes homeless because his par- at some point. In the tenth episode of the fourth ents have found out he has set up a meth lab season, called “Health”, Gus Fring takes Jesse in the house he inherited from his aunt. In Jesse to Mexico by force to make him try his hand at we see the relapse into seeking out the drug synthesizing ultra-pure methamphetamine in the and returning to using after adverse situations Juárez Cartel. There, he sees one of these super- or depressing episodes, such as in “Mandala”, labs, run by this criminal gang. Fring is a dan- when he feels guilty and sad about the death of gerous man who does not hesitate to eliminate his friend Combo and starts to shoot up heroin the boss of the Mexican cartel, who is compet- with his addict girlfriend. This episode offers fair- ing for the trafficking and distribution of metham- ly realistic scenes about the effects heroin has, phetamine on American turf. The methamphet- in clear contrast to the effects of methamphetamine trafficking by Mexican criminal gangs as amine. Injected heroin induces a wholly pleasant described in the series is plausible, given that sensation, characterized by a marked indiffer- the decrease in methamphetamine production ence to internal and external stimuli. The peak of in the US noted since 2003 was countered by euphoria occurs seconds after injecting the drug an increase in Mexican production. The Mexican and tends to last several minutes, while the feel- drug cartels became more involved in that traf- ing of well-being can last from four to six hours. ficking, and the amount of methamphetamine However, heroin does not induce psychomotor confiscated on the border between the US and action, given that it is a depressant of the central Mexico increased considerably in 2003.4 In 2008, nervous system. Large amounts of heroin can Canadian trafficking organizations increased their cause extreme drowsiness, with the risk of in- participation in meth production worldwide, while ducing a state of coma or decreasing the cough Mexican cartels invaded the market in the US.4 and expectorant reflex, which can cause one to choke on one’s own vomit. This is reflected in the tragic case of Jane, Jesse’s girlfriend, who dies in The different profiles of meth addicts precisely this way. The second season of Breaking Bad depicts in a On the other hand, methamphetamine also fairly realistic manner some of the existing patterns induces a fast peak of euphoria that can last for among methamphetamine users. On one hand, many hours, depending on whether it is inhaled, Jesse and his friends generally sniff or smoke smoked or injected, through activation of the the drug, so that moderate doses produce quick central nervous system by its effect of releasing effects such as euphoria, heightened attention, monoamines. At the end of the second season, a loss of appetite, increased libido and self-es- in episode thirteen, “ABQ”, Walter takes Jesse to teem, and improved mood. Yet Jesse appears in rehab. We see his affective deterioration, feeling the series as a true addict who does not limit the guilt at his girlfriend’s death. The situation Jesse amount of methamphetamine he uses because finds himself in is no doubt because of the af- he has unlimited access to it. In a scene from the fective deterioration characteristic of those who second season’s eleventh episode “Mandala”, chronically abuse methamphetamine, who fre- when Jesse meets Walter to talk business, we quently have problems experiencing pleasure see the effects associated with consuming high (anhedonia) and fall into deep depression from doses of methamphetamine as Jesse is stricken the exhaustion of cerebral reserves of dopamine

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and serotonin in the neuronal terminals.1 Through they consume meth because it is cheaper. They Jesse’s character, the series shows addiction will do anything to get the drug, even prostitute truthfully, since the affective problems and possi- themselves, as Spooge’s girlfriend does. The epi- ble cognitive deficit that Jesse experiences con- sode “Peekaboo”, in the second season, shows tribute significantly to perpetuating the addict- the marginal conditions in which this couple ive cycle, characterized by abuse, loss of control live, with a small child who is totally uncared for. and relapse.2 These two characters suffer from serious side ef- The third episode, “Open House”, in the fects that truly occur after chronic meth use; for fourth season, shows how Jesse increasingly example, both show evidence of malnutrition and loses control over his actions and seems quite poor dental health associated with serious cavi- unbalanced when, after killing Gale, he throws an ties and the loss of teeth. The latter is due to the interminable party in his house with other drug drug’s acidic properties combined with a lack of addicts, consuming huge amounts of metham- oral hygiene. Xerostomia (dry mouth) also adds phetamine. The situation degenerates, evolving to the dental problems resulting from metham- from dancing to violence. This episode shows phetamine use. Spooge and his girlfriend also the reality of methamphetamine use in the form have skin damage as a result of the compulsive of binges, which can last several days, and scratching that accompanies methamphetamine where the euphoric effects of the drug progres- use. Such injuries tend to get infected, resulting sively decrease over time, while dysphoria and in a bacterial cellulitis that spreads to become compulsive and repetitive behaviors increase. bacteremia and sepsis in some cases. This use profile is perfectly captured by Jesse’s In addition to these examples of methamphet- party, where after several days of euphoria and amine users in the series, two other individuals dancing, the guests start to become violent and use the drug but do not become addicts. This engage in risky sexual behavior. The behaviors aspect, which the series does not examine, is described in the series (which Jesse dramatizes) linked to existing differences in the population in are linked to pathological deregulation of the ce- terms of individual vulnerability of entering the ad- rebral circuits involved in pleasure and motiva- dictive cycle after sporadic or recreational drug tion caused by the addiction. So, taking most use. Experts believe that 12 to 20 out of every abusive drugs, including methamphetamine, 100 people who begin to use drugs will develop increases dopaminergic transmission in specific addiction. Yet the risk that these addicts relapse cerebral centers that reinforce the behavior of into using the drug, even after prolonged per seeking and consuming the drug, facilitating the iods of abstinence, is extremely high.2 In 2013, reiteration of learned behaviors and encouraging the Washington Post 6 published an article on the addiction. From the uncontrolled need to obtain type of person, known as a “functional addict”, the drug stems the relapse, the basis of which is who consumes methamphetamine and seems a pathological form of neuronal plasticity in the able to remain socially active. Some of the exam- excitatory glutamatergic system. Such deregu- ples mentioned were working mothers, or people lation means that the individual addict places holding down several boring and poorly paid jobs excessive motivational importance on stimuli who use meth to boost their energy and alleviate that predict drug availability and it reduces his the tedium of their social and working conditions, or her ability to stop using it.5 or university students wanting to improve their Meanwhile we have the characters of Spooge cognitive capacities. As has been mentioned, and his girlfriend, two addicts on the fringes of the addictive process depends on the drug use and disconnected from society. These characters and its interaction with the individual’s preexist- show the reality of chronic methamphetamine ing genetic or behavioral vulnerability. So some of addicts, who are often multi-drug addicts. But these people, perhaps the most vulnerable, enter because they cannot pay for cocaine or heroin, the spiral of addiction and lose control over their

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Medicine in Television Series

drug use to the point of failing at work and dis- Republic and the Russian Federation, as well as connecting socially. developing countries in Africa and Central Amer ica.9 In Spain, methamphetamine consumption is Could Breaking Bad encourage low due to its high price, and seems to be linked methamphetamine use? above all to elitist use on the gay scene.7 Though the series deals realistically with methamphetamine addiction and its devastating ef- References fects, some believe that Breaking Bad may have 1. Rusyniak DE. Neurologic manifestations of chronic encouraged consumption of this drug. In 2014, methamphetamine abuse. Psychiatr Clin North Am. several articles appeared in the Spanish press in- 2013;36:261-75. dicating an increase in the confiscation of meth- 2. Piazza PV, Deroche-Gamonet V. A multistep general amphetamine in the UK and rising use in Ger theory of transition to addiction. Psychopharmacology (Berl). 2013;229:387-413. many in the past five years. For some, this fact 3. Drug Enforcement Administration (DEA). Metham- could be related to the series, while others claim phetamine situation in the United States. Drug intel- that “it is more correct to say that the series has ligence report. Washington, DC: U.S. Department of made people aware of this drug”.7 On the other Justice; 1996. 4. Drug Enforcement Administration (DEA). Office of hand, a report from the DEA indicated that the Forensic Sciences, Special Testing and Research number of methamphetamine-related incidents Laboratory. Methaphetamine profiling program, fourth in the US in 2012 was the lowest since 2008, the quarter CY2010. Washington DC; 2010. year the series started. So it does not seem to 5. Kalivas PW, Volkow N, Seamans J. Unmanage- have influenced in the consumption of this sub- able motivation in addiction: a pathology in prefrontal-accumbens glutamate transmission. Neuron. stance. 2005;45:647-50. Though methamphetamine use could be 6. Matthews D. Here’s what ‘Breaking Bad’ gets right, dropping in the US, it remains high in Asia, and and wrong, about the meth business. The Washington worldwide consumption has become an epi- Post; 15 August 2013. 7. Navarro M. La devastadora droga de ‘Breaking Bad’ demic. According to the UN Office on Drugs and ya se toma en Catalunya. El Periódico; 21 November Crime (UNODC), it is estimated there are 25 mil- 2014. lion amphetamine users worldwide, a larger num- 8. UNODC. Annual Report 2008. Available at: www. ber than cocaine (14 million) and heroin users unodc.org/documents/wdr/WDR_2008/WDR_2008_ eng_web.pdf 8 (11 million). Furthermore, studies indicate that 9. UNODC. Annual Report 2013. Available at http:// methamphetamine synthesis and distribution has www.unodc.org/unodc/secured/wdr/wdr2013/ increased in countries such as Poland, the Czech World_Drug_Report_2013.pdf

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Notebooks of the Esteve Foundation Nº 42

Mad Men and Tobacco Addiction

Joan R. Villalbí

Don Draper is, in all likelihood, one of the most representative icons of the golden age that TV series are currently enjoying. Set in a New York ad agency in the 1960s, the show is a true and elegant reflection of a period characterized by social discrimination, and has reaped the most prestigious accolades since it premiered on the cable channel AMC in 2008. It scored four consecutive wins as Best Drama in the Em- mys, and three Golden Globes, totaling 20 awards over its seven seasons on air. Even before its finale, it was considered one of the best series in television history.

Big tobacco companies have used different strat- eral exhibition. Internal tobacco industry docu- egies to promote tobacco use for decades. Nat- ments revealed in North American court cases urally, direct advertising is the most significant, document this, and the work of Stan Glantz and and one of the most effective; billboards on the his collaborators at the University of California street, seen by the general public in their daily provides ample evidence. lives, is one of its favorite supports, as well as Mad Men is a successful TV series, which adverts in the printed press and spots on radio many consider a work of art. In recent years, and TV. In such adverts, it is common to show part of the creative talent that time back was em- popular figures smoking, and the stars of film ployed in films has migrated toward TV series on and TV were doing it from the 1920s onward. So channels like AMC and HBO. Mad Men is part of Humphrey Bogart and Lauren Bacall starred in this process. Since the series is set in the 1960s, tobacco adverts in the 1940s, but so did many when smoking was common in the US, tobacco more US artists, until the practice was declared il- plays a significant role, leading to the formulation legal in 1964. As governments in many advanced of this analysis from a double perspective: the societies adopted policies to reduce the damage viewpoint both of a fan of the series, and of a that tobacco was causing, for example prohib- public health professional involved for years in the iting the advertising and promotion of tobacco, prevention of smoking. the industry sought ever more subtle ways of promoting itself. One of these was through its The historical context of Mad Men presence in films or on TV. In recent years, it has come to light that both studios and artists signed The series Mad Men premiered in 2007 in the US, contracts with tobacco companies that led to at- on the cable TV channel AMC, and ended in 2015, tractive film stars visibly smoking, or even making after seven seasons. Set in New York throughout favorable comments on tobacco brands. These the 1960s, it focuses on an ad agency located tactics intensified in the 1980s, and it has been on Madison Avenue (hence the reference to “Mad documented that during the following decade men”, the men of Madison Avenue in ad agency the presence of smoking on-screen in Hollywood slang, since there were numerous agencies lo- films increased, especially in films rated for gen- cated in the area at that time). The drama follows

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the career of the creative Don Draper and the al public through the media. The detonators were people in his personal and professional sphere, the 1962 report by the Royal College of Physi- centering on ad agency business and the life of cians in London, Great Britain, and publication of its stars during several years of frenetic changes the US Surgeon General’s Advisory Committee in the US, up until the 1970s. This period allowed report in 1964. Statistics on tobacco use showed the series, using images and dialog, to place sev- the impact of the Surgeon General’s report, which eral themes center-stage: cigarette smoking, al- marked a clear turning point, since its publica- cohol consumption, persistent sexism, budding tion prompted many desertions from tobacco’s feminism, frequent adultery and infidelities, hid- cause. So 1963 was the year of greatest tobacco den homosexuality and homophobia, anti-Sem- consumption per capita in the US (this has been itism, and signs of flagrant racism. Throughout estimated at 4345 cigarettes per inhabitant over the series, events occur which pervade the ac- 18). After the Surgeon General’s report in 1964, tion: Kennedy wins the elections, the contracep- many states and cities began to pass regulations tive pill comes onto the market, the Vietnam War aimed at reducing tobacco addiction. This pro- breaks out, the damage that tobacco causes is cess led to the current situation, where 20% of documented, and so on. Yet perhaps its major adult Americans smoke, a ratio that in New York pillar, one of its main underlying themes, is the City drops to 14% of the population. In this city, deception people weave and their projection of one cannot smoke in the workplace, on public identity. We see characters living a lie, hiding key transport, in bars or restaurants, or on beaches elements of their identities, lives and past, who or in parks. (The fine for smoking in a public park are, moreover, constantly deceiving the people is $US50.) The cost of cigarettes is high due to closest to them. A certain parallel exists between specific taxes (in New York, the average price for a packet is $US12). Tobacco cannot be sold to such aspects and the ad agency’s core activity, persons under 21 in the city. Lastly, messages which builds an unreal image of the brands and warning against smoking, offering reasons to products it promotes to consumers. stop smoking are everywhere. In the early 1960s, tobacco use in the US had reached its critical point. For decades most adult men had smoked, and since the mid-1940s it The key tobacco moments in the series had been widely taken up by women too. Its so- Throughout the series, tobacco is constantly cial acceptance was widespread. One smoked present. The main character, his wife and many at work, on trains, in bars and in restaurants. of the adult characters are smokers. The ab- Advertising frequently laid claim to the presump- sence of tobacco regulation in the period means tive benefits of one brand over another, and its that they smoke in the office, in meetings, in bars less irritant properties. It was not infrequent to and in restaurants. The characters constantly show health professionals on cigarette adverts. smoke. In addition to tobacco’s omnipresence, In 1965, the prevalence of smoking was 42.4% there are three key moments when tobacco is not (51.9% of men and 33.9% of women). merely part of the atmosphere but plays a lead- Early studies incontrovertibly showing the ing role in the show: in episode one of the first damage caused by tobacco were published in the season (focused on tobacco advertising); in the 1950s. Foremost among them was Richard Doll’s twelfth of the fourth season (when they talk about pilot study in the UK and a study of cases and the damage tobacco causes); and in the final epi- controls by Ernest Wynder in the US. This knowl- sode of the seventh and last season (where lung edge began circulating in professional circles and cancer affects one of the main characters). We had a certain impact in the press, but it was not should review these moments. until the early 1960s that the relationship between In the first episode (named, like The Platters tobacco, lung cancer and other diseases became song, “Smoke gets in your eyes”), the agency is generally accepted and reached the wider gener- trying to win an important contract with the com-

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pany that manufactures the cigarette brand Lucky York Times entitled “Why I’m Quitting Tobacco”, Strike. They must combat a growing social per- in which he proclaims he is happy to stop pub- ception that tobacco is bad for one’s health (an licizing a product that kills its users, and that opinion the Reader’s Digest has just published), henceforth he will not accept tobacco companies as well as a prohibition by the Federal Trade as clients. Furthermore, he publishes the letter as Commission from evoking health benefits in ad- a full-page advert. Naturally, everybody keeps vertising as was previously common (the tobacco smoking in the office, while the agency has seri- company executives rant about these marketing ous financial difficulties and must lay off staff. Yet obstacles, with references to Russia and com- in the next episode, it wins new accounts and munism). To prepare for the meeting, Don Draper begins talks with the American Cancer Society, holds apparently trivial conversations with the which is possibly interested as a client, from the smokers around him, delving into their reasons for result of Don Draper’s advert against tobacco smoking and for choosing a brand. He also has a companies. meeting with a medical consultant, a psychoana- In the seventh season, at the end of the series, lyst, who indicates that an underlying element for the attractive Betty (Don Draper’s ex-wife), an ex- smokers is a death wish. In his meeting with the model and heavy smoker, undergoes tests after tobacco company executives, which develops suffering health problems and receives the diag- in rather an insane manner, where naturally any nosis of lung cancer. They tell her the prognostic concern about the damage tobacco may cause is is grim: she has a few months left, though she rejected or ignored (though as committed smok- may survive for a year if they undertake aggres- ers, they are visibly coughing), Don Draper, who sive treatment, which she refuses. So she pre- was creatively blocked, is struck by sudden inspi- pares for her death, notifying the people around ration and proposes an ad campaign that differs her, while she organizes her children’s future... from those that have been typical up to that point. and keeps on smoking. Furthermore, in the last He suggests ignoring any concern about tobacco episode, Roger Sterling also appears. He is the and health, and seeking connections with their character who indulges in every excess, with customers’ aspiration to happiness: based on heart attacks in his past since the first season. the smokers’ stories and identity. He advocates And he continues smoking, drinking and order- building the brand image based on colors, logos ing lobster and more champagne, along with his and slogans. Pure advertising: “Lucky Strike. It’s young partner. toasted.” While Lucky Strike was already a brand that used a play on words, “It’s toasted” refers Tobacco use in the series and during to the fact that during manufacturing, this tobac- the period co is toasted instead of just dried (other brands also do this, but they decided to make a feature of As mentioned above, tobacco use in the series it). Simultaneously, they sought a connection with reflects reality throughout the 1960s. At the start the customer by evoking the morning toast and of the series, set in 1960, smoking is common relaxed daily life. A surefire success. (In fact, this among adult men and women, except for old story is pure fiction, since the slogan “It’s toasted” people. Smokers smoke everywhere: naturally was coined decades earlier.) at home, but also on the train on the commute, at At the end of the fourth season, Lucky Strike the office, in bars and restaurants. Naturally, this abandons the ad agency after 25 years of con- means that smokers smoke heavily. Early data tracts and signs with another agency. In epi- tell us that in 1965, many smokers smoked more sode 12, “Blowing smoke”, the agency’s survival than a packet a day. So the levels of tobacco seems threatened by the consequences of this consumption shown in the series are in line with change, which affects its image. An attempt to contemporary reality. capture Philip Morris as a substitute client fails. Another element to note is that Don and Don Draper reacts and writes a letter to the New Betty’s adolescent daughter begins smoking in

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secret, a detail that also seems to reflect with cer- rather unreliable due to the publication of his let- tain realism the process by which some people ter on tobacco. began smoking back then. Equally shocking is how her mother, wanting to improve their rela- Tobacco’s consequences: tionship, offers her a cigarette in one scene, an reality and image act in which she seeks to create complicity. For people of my generation, this was not an unusual Tobacco’s negative consequences appear in the event in the family circle, or with certain teachers. series. Betty’s lung cancer, diagnosed at a sur- Nowadays it would clearly clash with our current prising age due to her youth, is probably the most sensibilities. striking (though it appears only in the final two The series is set in an ad agency, so this oc- episodes of the last season, among a number cupies a relevant space. There were no limits on of episodes). Roger Sterling’s heart attacks are tobacco advertising in those days. The federal there from day one, and tobacco shares its caus- prohibition against tobacco advertising on elec- al role along with other risk factors. But this does tronic media (radio and TV) came about in the not stop Roger smoking and he generally gives 1970s. The reality was that advertising expenses an impression of doing everything he can to en- for the tobacco industry were then far lower than danger his health while continuing to have a good in the early twenty-first century. What the series time. In the later seasons, Don’s cough emerges shows is fairly true to life, tobacco being one (as well as his problems with alcohol), which does of the important accounts for an ad agency. Until not stop him smoking. There are mentions of oth- the early 1960s, ad campaigns did not hesitate er risks linked to smoking. Perhaps one should to evoke the presumed benefits of smoking, us- highlight that the explosion that unleashes one ing doctors and other health professionals in of the main plot strands (Don’s false identity after ads. Facing concern about the damage caused the war) is the result of him dropping his lighter in by tobacco, advertising was reoriented to trans- spilled fuel. There is even a scene in which Me- mit feelings of happiness, relaxation and daily gan’s mother falls asleep in bed with a lit cigar life linked to their customers’ identity and aspi- ette, posing a risk that her daughter discreetly re- rations. Initially, no mention was made of luring solves. In general, the consequences of tobacco adolescents towards smoking, or of market seg- are present, but given little space. So, while it mentation by gender or race (though in later epi- is true that the series does not flinch from such sodes set in the late 1970s, a Philip Morris cam- consequences, they are barely communicated to paign did appear aimed specifically at the female viewers. Regarding tobacco, Mad Men viewers market). In my understanding, it is probable that basically receive many images of people smoking advertising’s omnipresence, along with consum- a lot, which sends out a message that smoking is er reality in 1960, made any segmentation un- normal behavior. This was the social perception necessary. In the fourth season, in the episode in the 1960s, but fortunately nowadays this is not described above, set in 1965, when Don Draper so, neither in the US nor in Spain. From this, a makes public that the agency will not accept any certain dissonance arises. more tobacco advertising because it is a product that harms its customers, he is trying to turn Tobacco and freedom of expression the loss of his largest account to his advantage, to position himself favorably in the light of publi- As other TV series and films, Mad Men poses cation of the Surgeon General’s 1964 report. In certain dilemmas. As mentioned earlier, it is well- later episodes, the American Cancer Society or- known that for years the big tobacco companies ganizes an event in his honor and it seems like a paid the film and television industry to guaran- good opportunity to win new clients, but we are tee its presence on-screen as a form of promo- informed that the executives of the large com tion. Tobacco is overwhelmingly present in Mad panies attending the dinner consider Don Draper Men, and naturally the Lucky Strike brand fea-

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tures. Throughout the series, many other prod- demarcate. My values are also in favor of free- uct brands appear, many of which remain on dom of expression, even when this challenges the market today (Jack Daniels, Gillette, Play- hegemonic opinions. I can confirm that every tex, Maidenform, Cadillac, Volkswagen, etc.), so time I see a rerun of Die Hard showing Bruce Wil- there has been a lot of speculation about product lis smoking with gusto, I curse the tobacco com- placement. According to Matthew Weiner, the panies, which paid to ensure its inclusion. And series creator and executive producer, only three yet, when I see the third film in the The Godfa- companies paid for placement: Jack Daniels, ther trilogy, which also received funds from the Heineken and Unilever (and also the Hilton, which tobacco industry, I cannot do so. Perhaps the apparently made a payment after appearing in an difference is in the distinct pleasure that one and episode, as an expression of gratitude). The oth- not the other give me, but maybe this is simply er brands and products that appear (up to a hun- a reflection of the dilemmas that we perceive life dred) were placed to give the series more realism, throws at us at certain ages. with no commercial agreements. One should not Like many other complex works, Mad Men forget that there are storylines, especially in cer- can be read on several levels. For a superficial tain periods and places, where the absence of and occasional viewing of the series, I think it tobacco could affect their authenticity. This is not transmits a favorable message about smoking just true for tobacco, but also for alcohol, for sex –that which is visible. On another level, of full and, in reality, for many human behaviors and as- viewing, the message is more complex. And on pects of daily life that can be related to health or yet another, a fuller and perhaps even more so- the beliefs of a segment of viewers. phisticated reading will capture the series’ finer We know that to reduce tobacco smoking in details, where a message against smoking will adolescents, different forms of their advertising emerge, as will a characterization of the indus- and promotion must be prohibited. I personally try and the visibility of its consequences at the documented the artful practices of the tobacco series’ end. It seems that, on the whole, in the industry in our country, which were totally at odds lives of people who watch Mad Men, the overall with the self-regulating codes they claimed to impact we hope it may have on our attitude to adopt. I was also an active agent in the process tobacco will probably be modest. And so, aware leading to Spanish Law 28/2005 that regulated not only of tobacco’s role in the show, but also this issue in a positive manner. Nevertheless, I of the enjoyment the series has given me, and believe that the border between freedom of ex- bearing in mind the values in which I believe, I pression and censorship is sometimes tricky to wholeheartedly recommend it to my friends.

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Notebooks of the Esteve Foundation Nº 42

The Walking Dead and the Collective Imaginary on Epidemics

Josep M. Comelles and Enrique Perdiguero Gil

If Mad Men and Breaking Bad are the two series that have taken the cable channel AMC to such great heights as its competitor, Premium HBO, this post-apocalyptic tale based on a Robert Kirkman comic depicting a world populated by zombies is the show that has brought it audiences in the millions, greater even than many free-to-air productions. Premiered in 2010 with over five million viewers, it has managed to multiply this figure threefold in its recent seasons, approaching fifteen million viewers. Such a favorable reception enabled AMC to try its luck with a sequel set in Los Angeles, Fear the Walking Dead, a strategy that so far has shown fairly good returns.

Though series such as Mad Men, Breaking Bad, Epiphany of the undead Fargo and True Detective scooped the major in- In 1943, Jacques Tourneur directed the film ternational awards, in the light of data from coun- I Walked with a Zombie, shortly after publication tries that publish audience levels, The Walking of Voodoo Death,1 a foundational article, based Dead is the most-watched series on cable TV. on ethnographic sources, regarding the physio The same occurs in Spain. Is this a further ex- logical mechanisms related to voodoo death. ample of viewers’ preference for action and violence over complex and convoluted storylines? The living dead and psychosomatic medicine Perhaps, but the truth is that the series tries to were broached in a centuries-old debate on the go beyond the horror-series stereotype, and aims capacity of witchcraft and spellcasting to sum- to analyze how far human beings will go when mon and condemn souls to wander the earth. struggling to survive. The Walking Dead has not An example is the myth of the Santa Compaña just earned viewers’ applause, but also garnered (“Holy Company”), a procession of the dead that academic interest. Theses, monographs and winds through the woods of Galicia, prompting dozens of articles in science journals focus on villagers to lock their doors after sunset and erect the walking dead and its groups of survivors. Un- cruceiros (calvary crosses) at crossroads to ex- der the umbrella of such success, zombies and orcise them. the undead are once again clamoring for atten- Tourneur managed to conjure the mystery of tion, since The Walking Dead is another link in the the border between life and death, the intimate chain of audiovisual products focused on such relation between reality and psychotherapy, by figures. In these pages, we highlight some of the employing visual ellipsis prodigiously and ele cinematic milestones related to the living dead, gantly regarding a beautiful undead woman. He their close relationship to the collective imaginary knew how to visually represent the mystery of the on epidemics and how this tradition crystallizes in Santería religion in a clinic for psycho-neurotic the series, along with its peculiarities. disorders. Prior to and even more ably than in

1 Written by Walter B. Cannon in the magazine American Anthropologist, in 1942.

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Ingmar Bergman’s The Magician (1958), he de- lently invaded the cities, carrying the Black Death. picted the contrast between the beliefs and cul- The Flying Dutchman, a ghost ship, still haunts a tural practices of magic, and medical rationalism. collective imaginary that builds on the experience This is because, in contrast to the Swedish direc- of sailing ships adrift which, an epidemic having tor, he speaks of the present, not of a figure of killed both crew and passengers, roam the seas the past. at the mercy of wind and wave endlessly seek- The undead, lost and wandering souls, form ing peace. A barquentine is likewise the improb- part of an ancient collective cultural imaginary, able mode of transport in the 1940s by which the which drew new life from the romanticism of protagonist of I Walked with a Zombie reaches the Brothers Grimm and folklorists, Washington his destination in the British West Indies (a visual Irving’s Tales of the Alhambra (1832), many of homage to Murnau?). This ship, however, is not Edgar Allan Poe’s short stories, Gustavo Adolfo plagued by any rats, undead or epidemic, since Bécquer’s Leyendas (1854–1864) and the recov- the witchcraft is on the island and forms part of ery of Oriental folklore.2 Bishop (2010) considers, a world that clashes with the rationalism of the erroneously, that zombies in film correspond to clinics. highly idiosyncratic aspects of twentieth-century American culture. He does not take into account A cinematography of wandering souls the genealogy of the undead in European literature and film. Spirits that become flesh populate Murnau’s and Tourneur’s visual magic has per- stories retold beside the hearth, while the wind haps faded over time and from the tapestries of moans outside and rain batters the shutters. At memory. After the Second World War, film recov- the height of positivism, Allan Kardec (1804–1869) ered Dracula the vampire, but not zombies. It is wished to bring them to life. Clustered around tempting to imagine that Tourneur raised the bar the lamp, believers invoked their presence, drafts so high in terms of sophistication and narrative el- without a source wafted the curtains, and the liv- egance that later creators dared not follow in his ing were carried off into trance by spirits. In The tracks. Yet the British film company Hammer gen- Canterville Ghost (1887), Oscar Wilde wrote ironi- erated extraordinary interest in “Draculas”, Chris- cally about Americans who made fun of British topher Lee playing the role, in which he explored ghosts, and in Dracula (1897), Bram Stoker invit- the vampire’s sexual and erotic dimensions. Be- ed the undead into Victorian drawing rooms as if tween Murnau’s neo-Romanticism, Nosferatu’s they were an epidemic vector. Yet filmic epiphany monstrousness and Christopher Lee’s Gothic yet of the undead should be attributed to Nosfera- very British elegance, there was, however, narra- tu (1922), by F.W. Murnau. It is a palimpsest of tive and visual continuity. And so it was, until in the Bram Stoker’s work, and an extraordinary visual year of May 1968, with Vietnam escalating and recreation blending expressionism and neo-Ro- race riots erupting in Pittsburgh following Martin manticism. Nosferatu emerges from his coffin in Luther King’s assassination, an unknown film- the bilges of a barquentine swarming with rats, maker named George R. Romero directed Night on which no souls remain alive, to alight in a ro- of the Living Dead (1968). In the midst of the Cold mantic Bremen. Rats, sailing ships, quarantine, War, decaying corpses return to life, stepping, like epidemics... After the First World War, the deadly Lazarus, from shattered tombs in all their rotting “Spanish flu” revived a fear of the plague in the glory. For reasons never fully explained, they make western cultural imagination, a scenario in which the same gestures as Nosferatu, and feed on the rats arrived by sea in the holds of ships and si- living until their brains are destroyed.

2 Lafcadio Hearn (1904) saw this in Japanese culture. Some of his stories evolved into a film masterpiece on the undead, the episode “The Woman of the Snow” in the marvelous Kwaidan (literally “strange stories”, 1964), by Masaki Kobayashi (1964).

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If, in Nosferatu, the narrative makes a link be- curse turned them into waxy damsels or anemic tween the plague and vampires, playing on the youths, Romero’s walking dead are rotting Laza- cultural imaginary, epidemics were not perceived rus types who take over the world.3 as a threat in 1968, but the apocalyptic context Now enthroned in the pantheon of popular of radioactivity certainly was. Dracula’s elegance, culture thanks to Romero’s genius and the ev- midway between bourgeois and aristocratic, from eryday life he portrayed to depict the tragedy, Bela Lugosi to Christopher Lee, and his capac- the undead have become an icon of postmod- ity for manipulating social relations to reaffirm his ern society. That society has also digested the own power and feed on the blood of the living, phenomenon, once more imbuing it with mean- is absent from these putrefying, twisted, bleed- ing and, to a certain extent, shedding any crit ing and dirty corpses that move by mere instinct. ical dimension it had of late-twentieth-century Yet precedents exist, such as representations of north-American society. Yet many studies on the Mr. Hyde in the successive film versions of Ste- subject reference specific aspects of the political venson’s novel. However, Hyde is our hidden discourse inherent in zombie film and TV. Night ego, lacking feeling, cold and calculating, and of the Living Dead became a cult film and the violent to boot, while the walking dead are beasts departure point for a genre that would overflow in a strict sense. They move due to an electrical the borders of the film medium to invade graphic instinct and only respond to simple stimuli such novels, including that which inspired the series as noise, or the expectation of flesh. we are looking at, The Walking Dead, in the early Night of the Living Dead could be classed twenty-first century. as a docudrama about the first night of the apocalypse, perhaps not too far removed from On plagues, epidemics the Biblical tale, but with millions of Lazarus fig- and other calamities ures wandering the earth. The story, which falls within the context of fears that were reflected Epidemics, since the metaphoric reference to the in US cinematography in the 1950s, highlights plague in Nosferatu, have been a subject less the human species’ practical capability for sur- visited than others in the entirety of the cinema- vival and its absolute dependence on technology. tography focused on the field of health, disease Meanwhile, it claims as its own the phrase homo and healthcare in the twentieth century. Neverthe- homini lupus (“A man is a wolf to another man”) less, we can highlight several films for their quality when trying to survive among supposed equals, or their success. Here are various examples. Elia in spite of the contention strategies of the state’s Kazan’s Panic in the Streets (1950) is nowadays armed forces, which quickly break down into the an interesting realist tale, likewise packed with violation of any notion of right and the total domi- metaphors and symbolism, bearing substantial nance of violence. ethnographic and historical value. It traces an Night of the Living Dead, filmed in dirty, epidemiological investigation into a classic out- gloomy and sinister black and white, when color break in the port of New Orleans, originating from was marching toward absolute hegemony of the a human vector. Almost half a century later, Out- medium, is a cultural product of the Cold War. break (1995) reflects the technical response and Here, the plague’s etiology is not taken into con- intervention protocols concerning an outbreak of sideration, though the living, cannibalized by the hemorrhagic fever of a viral origin entering the US, dead, once dead, join their predators. If Victo- a theme covered with more solvency in Contagion rian vampires abducted their victims and the (2011). In Panic in the Streets (1950), the refer-

3 Romero’s fable has several sequels, in which the filmmaker used the walking dead to speak of survival in a capitalist society, such as in Return of the Living Dead (1978), where the living are entrapped in those cathedrals of consum erism, sprawling north-American shopping malls.

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ence point is the plague and prevention; in the via the emergence of the figure of the undead. other two, the emphasis is on capacity for techno- It is not by chance that Blade and The Walking logical response to epidemic outbreaks. Conta- Dead have evolved from two graphic novels in gion also stresses the importance of investigation which viral infection is the major cause of the in the streets, an aspect that was portrayed in the apocalypse, in a context in which the threat of TV production And the Band Played On (1993), biological war generated after 9/11 has fed into centered on investigations leading to the discov- popular fears. ery of the human immunodeficiency virus (HIV). The three film franchises of Blade (1998) and Before Outbreak, and in the context of irra- its sequel, Blade: the Series (2006), stay within the tional fears of the Cold War with its epidemics classic blueprint of the vampire genre, though with of UFO sightings, to which Spanish weekly El more gore, a lot more sex and a production design Caso paid riveted attention, Robert Wise’s The that systematically employs the present world as a Andromeda Strain (1971), seemingly an exercise referent for the underworld of the vampire minor- in science fiction so as to remain politically cor- ity. A recent trend, illustrated mainly by various TV rect, highlighted the problem of biological weap- series, is to treat the living dead and vampires as ons and their more than probable confinement a minority who manage to coexist with humans. to installations on the margins of citizens’ view This is the case of True Blood (2008–2014), Being and control. Its most interesting aspect is its re- Human (2008), The Vampire Diaries (2009–) and alistic portrayal of operational protocols in what its spin-off The Originals (2013–), among others, were probably the first laboratories specialized in but especially the caustic British miniseries In the studying uncontrolled epidemic outbreaks. At the Flesh (2013). This BBC series accepts the hypoth- time of screening, no collective awareness exist- esis of apocalyptic viral infection, which it defines ed, much less any “moral panic” (Garland, 2008), ironically as “partially dead syndrome” (PDS) en- regarding any epidemic that was not bacterial in abling, on one hand, an interesting treatment on nature. That same year saw a minor cholera out- managing a chronic disease, and on the other, a break in Spain. In the quarter-century between highly critical dissertation on the tolerance of dif- The Andromeda Strain and Outbreak, epidemic ference in current British society. risk from a virus became a more patent threat, albeit in limited circles, such as in the cases of the Cannibal undead and human assassins Marburg and Ebola viruses. This is a new model for limiting and curtailing risks, based on violent When the channel AMC announced the screen- outbreaks, but modeled by political and rhetori- ing of The Walking Dead, critics were aware that cal discourses on security. Despite its early con- among the series creators were Frank Darabont, finement to specific behaviors and risk groups, considered one of Hollywood’s best scriptwrit- HIV/AIDS signified the definitive awareness-rais- ers; Greg Nicotero, the prestigious special effects ing on the coupling of epidemics and globaliza- creator,4 and Gale Anne Hurd, a successful pro- tion, stoked even further in recent years by alerts ducer. Another guarantee was that the idea and regarding bird flu, influenza A virus (N1H1) and scripts originated from the authors of the homon- the latest Ebola virus outbreak. ymous graphic novel created by Robert Kirkman. Yet apart from these films in which collective This roll call meant the series would likely have a terror arises from the “outbreak” of disease, the certain quality within a television panorama that idea of the apocalypse associated to an epidemic had changed profoundly in recent years. The se- is receiving unexpected film and TV development ries has introduced new narrative languages in

4 Nicotero’s first large project was, in fact, on a George G. Romero film, Day of the Dead (1985). He is considered one of the heirs of the tradition of creators of strange creatures, like Ray Harryhausen and especially Tom Savini, who he trained with.

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relation to film, and what is more important, ones Although in the classic representation of accessible to world audiences through the Inter- the zombie in The Walking Dead, the referents net, allowing broad swathes of viewers access to the Paris-based theater of Grand Guignol to the production of genre that, in film, would be (1897–1962) are fairly clear, the series aesthetic, more on the fringe. in faded, slightly dirty tones, under gloomy skies, The Walking Dead’s genealogy no doubt in- tries to reinforce, at least in terms of landscape, cludes both Night of the Living Dead and 28 Days a certain documentary air. This is probably be- Later (2002), but with nuances. In Night of the cause it is dealing with landscape. If in Night of Living Dead, the cause of the dead’s resurrection the Living Dead the protagonists are the living is never clarified, but they are dead, while in 28 dead, this is not the case of 28 Days Later or The Days Later and in The Walking Dead the scripts Walking Dead. mention an infection of a more viral than bacterial According to García Novo (1989; 8–9) the nature, which means that the zombies are not “re- term epidemiai had been interpreted like “visits suscitated” but “transformed”, as with the idea of overseas”, though he emphasizes that the title Partially Dead Syndrome in In the Flesh. Neverthe- probably refers to “being caught unprepared”. less, representation of the undead in The Walking Both definitions correspond very exactly to the Dead uses referents such as Night of the Living fundamental themes in The Walking Dead. On Dead rather than the image of a waxy adolescent one hand, the crisis the epidemic brings, in this as in the British series (closer to the adolescent case in its actual meaning, is skillfully narrated vampires in The Twilight Saga, 2008–2012). The in the first episode. The plague surprises the series dramaturgy is therefore far removed from protagonist, Rick Grimes, while he is convales- the idea of a chronic illness, whether degenerative cent in hospital, and from this unforeseen situ- or not, but rather placed in a setting much closer ation the plot arc for the first season develops, to the original model of the resuscitated corpse, focused on the search for a vaccine and cure, matching a culture that systematically practices leading them unsuccessfully to the Center for thanatopraxis and embalming before burial. Disease Control in Atlanta. This first season, in Even so, by opting for transmission through reality a six-episode miniseries, is the most illu- biting, it harks back not only to vampires, but also minating of all, because it illustrates the idea of to the cultural imaginary of rabies contagion, a the crisis, the unimaginable and, meanwhile, the topic that had significant cultural impact in the hopeful itinerary of the quest for health of the early twentieth century. It also evokes dementia- founding group. tion leading to animalization, whose most obvi- From the second season onward, the tone ous references in history are those associated changes, on the assumption it is an out-of-con- with late-stage syphilis infection, or with alcohol- trol epidemic and that the forces that might have ism and epilepsy. However, the series goes be- halted it have failed, leaving no alternative. In view yond this, since it deals with a type of clinical de- of the infection’s characteristics, “clinical or ther- cerebration, which governs maintenance of the apeutic” solutions are going to involve forceful most primitive phylogenetic structures in homo responses. For this reason, in the third season, sapiens and which, curiously, is cured by physi- Carol applies euthanasia and amputates a leg of cally decerebrating the zombie. one of the members of the group to stop the gan- The path followed by The Walking Dead grene that has developed from an infected bite. therefore clashes with the current evolution of At the time of writing in its fourth season, the duo the vampire genre, centering on post-adolescent made up of soldier Abraham Ford and Dr. Porter bodies, or on versions that accentuate virility are offered as a hope for a cure, an argument for to a greater or lesser degree, such as Wesley survival. Snipes in the saga Blade, or Amazons like Le- It is not the apocalypse caused by the “par- onor Varela in Blade II, far removed from the clas- tially dead” and the search for a cure which have sic manly style of Christopher Lee’s Dracula. been key to the popular and academic success

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of this series, but the manner of portraying the any kind of pathology, but to the deployment of development of those fighting against the un- skills and the testing of these in order to resist. dead. In most apocalyptic series (and in films The root difference is in that it is not necessar- such as The Road, an adaptation of the novel ily “the apparently strong” who survive, a nuclear by Cormac McCarthy), as well as in the series argument when designing the protagonists of we are looking at, the “good guys”, that is, the some series (in the case concerning us, Rick), survivors of the human race who are fighting to but those who know how best to adapt to daily save that heritage, evolve from perspectives we survival without necessarily being leaders or he- might call “democratic American” toward radi- roes. The best is not the one who dies, but the cally totalitarian and neo-fascist attitudes. Their one who reaches the end. Yet this character is view of the undead is fundamentally racist, with a distrustful, given that “he comes to know what he seemingly unstoppable crescendo of violence. All has done”. Allué does not base her argument’s of this leads to a collapse of values, generally jus- mainstay on a moral Christian model, a stance tified as a form of safeguarding family values, in that would be overwhelmingly present in the terms that are difficult to comprehend in Europe. heroes’ ideology and in the idea of redemption In The Walking Dead, the characters –especially through death, another common theme in series Rick Grimes– evolve toward often clinical levels of scripts. To a certain extent, surviving means go- paranoia. This could also be interpreted as what ing unnoticed, but in The Walking Dead, if you do is known as a “psychic epidemic”, taking on ele- so, you do not survive. ments of classic descriptions of folie à deux, or The survival narratives that appear in the se- shared psychosis, as seems evident in Rick’s and ries signify a marked contrast. So, in some char- Carol’s attitudes in the fifth season. So not only acters’ makeup, especially in the development do we have the cannibal undead but also the of the protagonist Rick Grimes and in the moral transformation of the “good guys” into a band of coolness of his adolescent son, Carl Grimes, serial killers whose paranoia urges them even to both appear as heroes, though often ruthless. kill each other. So the play between the hell rep- Compared to them, Carol’s logic and common resented by “the other” and one’s internal hell is sense are much more closely aligned to the sur- one of the more fascinating keys to the series. vival model Allué describes. At a certain point, The storyline resulting from this type of “psy- she is forced to execute a girl who has become chic epidemic” highlights the massive use of mili- mad, just because she has gone mad, and un- tary technology, emphasizing the high degree of der the circumstances, she endangers the other identification of broad sectors of North American group members. Carol’s character is perhaps the culture with the fetishism of firearms, including most interesting. She represents a survival praxis the crossbow. It appears this scenario is often based on systematic observation of the facts and presented cynically: surviving at all costs as a on rational decision-making in extreme circum- payoff for literally becoming killers, or, if you pre- stances. This leads to her being banished for ap- fer, modern-day gunslingers in a new film genre plying a measure that was inevitable in a situation that has infused the old forms of the classic west- without alternatives. The contrast between Rick ern with fresh blood. and Carol, carefully managed by the scriptwrit- Marta Allué (2008) has written a great deal ers, also links highly idiosyncratic US cultural about survival in terms that directly contradicts contexts, where the weight of moral and religious its mode of representation in The Walking Dead. discourse in the media underlines much of the The plot line of the series, based on concentra- scriptwriters’ work. tionary literature and on a careful ethnography, is that survival is the product of social and cultural Wild men in the looking glass learnings, even in situations of maximum violence, such as surviving in extermination camps. Two decades ago, the anthropologist Roger Survival, defined as a practice, does not lead to Bartra (1992) published Wild Men in the Look-

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ing Glass. The Mythic Origins of European Oth- and the doctor (once again, the hope of a cure) erness, a compelling study on the imaginary of to their destination. otherness in Medieval Europe, in which the end- We do not know how the series will evolve less greenwoods hid chimera and mysterious in future. The latest season has focused mainly beings, wild men and women, and monstrous on the almost impossible rebuilding of civility for creatures. In the vastness of the Medieval forest, those who have been stripped of their theoreti- cleared land for farming and cities were spaces cal humanity on their journey toward survival. On of light. In The Walking Dead –in contrast to the their odyssey through nature, their paranoia and intensely urban 28 Days Later, and with the ex- profound distrust in human beings themselves ception of the first season– woods, fields and have begun to spread like another epidemic. copses straddling abandoned highways and rail- This situation stems partly from their incapacity way lines are the setting for the walking dead. to manage resources other than those of tech- Their transformation turns them into beings who nological society. They are not country people; live in nature, occasionally shut into houses or they depend on what remains in supermarkets. warehouses they do not know how to escape Even domestic animals no longer exist. Yet there from, and they walk day and night in search is always gas for vehicles, and ammo to load the of what, we suppose, is their food. Instead of magazines of their assault rifles. deserted cities, fields of undead. Replacing the idea of quarantine, the exclusion of the savages, Conclusions or shutting the pathological into institutions, the survivors, the sane in The Walking Dead, must It is not a foregone conclusion that The Walking live enclosed. They live barricaded in refuges, Dead, despite many filmic qualities, will join that in small redoubts, where they can dig in, con- cult group of series of the last decade. There is demned to foray out to replenish their water a lot of competition. Academic production on supply or stock up on food, moving outdoors the series is in itself surprising, given that most at risk, like the Spanish troops holed up in army of the elements it uses stem from a well-founded blockhouses in the Battle of Annual, surrounded cultural genealogy, already dealt with in film, the by the hordes of the Rif. The world is no longer roots of which delve at least as deep as Euro human: nature, the undead included, have taken pean Medieval cultures. Even the plague, as over, and as if it were a new Middle Ages, the ref- such, is directly linked to the imaginary of mod- uges are surrounded by theoretically impregna- ern and Medieval plagues, and the undead, to ble walls, or, in the greatest of paradoxes, prison the living dead that populate folklore. Neverthe- and its prisoners become a space of freedom. less, millions of viewers worldwide avidly watch The play of contrasts between the dangers the episodes as if zombies were a novelty. Such of the epidemic that govern the natural world and articles adventure numerous hypotheses, but the need to build spaces of exclusion is interest- perhaps it is simply the “it works” factor of au- ing from a comparative viewpoint. The typology diovisual products –such a hard factor to define. is suggestive in itself: in the second season, the farmstead; in the third, the free prison compared References to the Governor’s enslaved community, the rail- way station and its warehouses; and in the latest −− Aguado Peláez D. Imaginario postapocalíptico en las series de televisión norteamericanas tras el 11S: análisis season, urban utopia, with links to the France- de The Walking Dead (AMC, 2010-). In: Espacios de co- Ville in Jules Verne’s The Begum’s Fortune municación: IV Congreso Internacional de la Asociación (1879), is seen as hygienic, as a blueprint for civil Española de Investigación en Comunicación. Bilbao: society which the group of barbarous survivors Asociación Española de Investigación de la Comunica- ción; 2013. p. 1091. who accompany Rick and Carol must assimilate. −− Allué M. La piel curtida. Barcelona, Bellaterra; 2008. They reach it through a kind of initiatory journey −− Bartra R. El salvaje en el espejo. UNAM, Ediciones ERA; that is the result of choosing to take the sergeant 1992.

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−− Berk I. The Walking Dead as a critique of American de- −− Lavia D. Epidemias y pandemias fantásticas en el cine. mocracy. CineAction. 2015; 95. Cinefania, March 2009. (Consulted on 13 May 2014.) −− Bishop KW. Dead man still walking: a critical investiga- Available at: http://www.cinefania.com/te rroruniversal/ tion into the rise and fall… And rise of zombie cinema. index.php?id=188 Arizona: University of Arizona; 2009. Ph. D. Dissertation. −− Nuckolls C. The Walking Dead as conservative cultu- −− Bishop KW. Dead man still walking. Journal of Popular ral critique. Journal for Cultural and Religious Theory. Film and Television. 2009;37:16-25. 2014;13:102-10. −− Bishop KW. American zombie gothic: the rise and fall −− Pirie D, Ibeas Delgado JM. El vampiro en el cine. Barce- (and rise) of the walking dead in popular culture. Jeffer- lona: Círculo de Lectores; 1977. son, NC: McFarland; 2010. −− Porras-Gallo MI, Davis RA. The Spanish influenza pan- −− Carrasco Asenjo M, Jimeno Maestro J. La epidemia de demic of 1918-1919. Rochester: University of Roches- cólera de 1971. Negar la realidad. Revista de Adminis- ter Press; 2014. tración Sanitaria Siglo XXI. 2006;4:583-97. −− Pulliam JM, Fonseca AJ. Encyclopedia of the Zombie. −− Cocarla S. Reclaiming public spaces through the perfor- The Walking Dead in popular culture and myth. Santa mance of the zombie walk. In: Smith R. Braaaiiinnnsss! Bárbara, CA: ABC-CLIO; 2014. From academics to zombies. Ottawa: University of −− Rawlings R. Survivors and victims: gothic feminism, de- Ottawa Press; 2011. construction and colonialism in “I Walked with a Zom- −− García Novo E. Introducción a los libros de epidemias. bie”. Meaghan Walsh Issues in Cinema Theory; 2008 In: Tratados Hipocráticos V. Epidemias. Translation, intro- (Spring). ductions and notes by Alicia Esteban, Elsa García Novo −− Redfern N, Steiger B. The zombie book: the encyclo- and Beatriz Cabellos. Madrid: Gredos; 1989. p. 7-19. pedia of the living dead. Canton, MI: Ink Visible Press; −− Garland D. On the concept of moral panic. Crime, Me- 2015. dia, Culture. 2008;4:9-30. −− Roche D. Resisting bodies: power crisis/meaning crisis −− Gubern R, Prat Carós J. Las raíces del miedo: antro- in the zombie film from 1932 to today. Revue Interdis- pología del cine de terror. Barcelona: Tusquets; 1979. ciplinaire «Textes & contextes», No. 6 (2011). Discours −− Hand RJ, Wilson M. Grand-Guignol. The French theatre autoritaires et résistances aux XXe et XXIe siecles. of horror. Exeter: University of Exeter Press; 2002. 28 November 2011. (Consulted on 13 May 2015.) Avai- −− Hand RJ, Wilson M. London’s Grand Guignol and the lable at: http://revuesshs.ubourgogne.fr/textes&contex theatre of horror. Exeter: University of Exeter Press; tes/document.php?id=1355 2007. −− Tabernero Holgado C, Perdiguero Gil E. El cine y las −− Hand RJ, Wilson M. Performing Grand-Guignol. Playing dimensiones colectivas de la enfermedad. Revista Me- the theatre of horror. Exeter: University of Exeter Press; dicina y Cine. 2011;7:44-53. 2015. −− Tabernero C, Perdiguero-Gil E. Cine y medicina: imá- −− Hearn L. Japan. An attempt of interpretation. New York: genes sobre la salud y la enfermedad. In: Brigidi S, edi- Macmillan; 1904. tor. Cultura, salud y cine. Tarragona: Publicacions URV; −− Lavia D. Epidemias y pandemias en el cine. Quintadi- 2015. mension, March 2009. (Consulted on 13 May 2014.) −− Tratados Hipocráticos V. Epidemias. Translation, intro- Available at: http://www.quintadimension. com/televi- ductions and notes by Alicia Esteban, Elsa García Novo cio/index.php?id=243 and Beatriz Cabellos. Madrid: Gredos; 1989.

-68- Notebooks of the Esteve Foundation Nº 42

Angels in America, The Normal Heart and Positius: HIV/AIDS in TV Series

Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Although the human immunodeficiency virus (HIV) and AIDS have been explored in TV series of a gay bent such as Queer as Folk (Channel 4, Showtime) and Looking (HBO), the fact is that, to date, they have only been examined more deeply in shorter formats. Such is the case with Angels in America, a miniseries produced by HBO in 2003, which narrates the spread of the epidemic in the midst of the Reagan era. It is also true of the more recent The Normal Heart (2014), also by HBO, a movie for TV that travels a little further back in time to describe the early years of confusion surrounding an unknown virus. Yet rarely has this infection been dealt with on television away from the gay stigma. One example can be found in the TV film Positius (2007) by Catalan channel TV3, starring two heterosexual women infected by the disease.

How does a society react to the threat of a new known about what was initially branded the “gay disease? And if that disease –apparently– only af- cancer”, whose cause was a total mystery. The fects a specific collective? How long would a gov- infection was only recognized when the patient ernment take to respond? How would it manage developed Kaposi’s sarcoma, a cancer caused the fear of the unknown? And once known, how by a virus that produces purplish lesions under does the stigma develop? How are your world the skin, in the lymph nodes and other parts of and your surroundings transformed? Do your pri- the body. orities in life change? To answer these questions Set between 1981 and 1984, the TV movie that arise with the human immunodeficiency virus relates how society, the government (President (HIV), we will analyze the North American fictions Reagan having recently entered the White House) Angels in America and The Normal Heart, and and the US medical sector decided to ignore the the Catalan production Positius –the first, a mini- early spread of the epidemic. The film centers on series and the other two, TV movies. a group of gay activists who embark on a cam- In both American productions, the stigma paign to call attention to this infection which ap- caused by HIV is mainly told through male pro- parently only affects gay men. The scriptwriter tagonists, men who have sex with men (MSM), Larry Kramer used his own experience in New who, as well as fighting the disease, must also York in the early 1980s to write this TV film that confront the social rejection generated by a dis- won several awards in 2014, among them an ease associated with sexual licentiousness and Emmy for Outstanding Television Movie. homosexuality. In contrast, Positius portrays two The miniseries Angels in America was devel- heterosexual women infected by the disease. We oped shortly afterwards, in 1985. Reagan was will start by examining the American productions, still in the White House, but AIDS was no longer since they occur chronologically in time, and last- an unknown word, albeit highly stigmatized. The ly look at how the Catalan fiction has dealt with miniseries focuses on the story of five people (four this terrible epidemic. men and one woman) affected by the disease in The Normal Heart portrays the early years one way or another. The four men practice sex of AIDS, a period in which almost nothing was with other men, though one of them, Republican

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and Mormon, is married with a wife. The pro- in the hallway, they tell him that hospital staff will duction earned eleven Emmys and five Golden not deliver the food to the rooms for fear of get- Globes, in each case including Outstanding Tele- ting infected, the same reason the maintenance vision Movie and Best Miniseries, respectively. technician refuses to fix one patient’s TV set.

Diseases from which Discovery of the virus that causes the protagonists suffer the disease

Neither fiction deeply examines medical treat- In Angels in America, set in 1985, Cohn’s doc- ment of the infection, though Angels in America is tor can give his patient a more detailed expla- somewhat more explicit on symptoms. Two of its nation than Doctor Brookner can. By then, the lead characters, Prior Walter (Justin Kirk) and Lou virus causing the infection had been identified (Ben Shenkman), are a couple until the former (in 1983, by scientists at Paris’s Institut Pasteur), confesses he has caught HIV. When Lou ques- and it was known that those infected underwent tions the accuracy of the diagnosis, Prior Walter a drastic decrease in their white blood cell count. lists his symptoms: Kaposi’s sarcoma, the pres- The series, however, does not accurately re- ence of protein in his urine (from the effect of HIV flect the information that was known, as reflected on his kidneys), diarrhea and blood in his feces. in the explanation the doctor gives Cohn after The other character infected is Roy Cohn telling him his diagnosis: (Al Pacino), a highly influential Republican who “Nobody knows what causes it. [This state- hides his homosexuality to stay in power. Cohn ment is false because HIV had already been visits his doctor with a clinical profile of lesions identified.] And nobody knows how to cure it. from Kaposi’s sarcoma, inflammation of glands in The best theory is that we blame a retrovirus, his neck, groin and armpits, oral candidiasis and the human immunodeficiency virus. Its presence fungus under his nails. is made known to us by the useless antibodies which appear in reaction to its entrance into the Ignorance of the transmission routes bloodstream through a cut, or an orifice. The antibodies are powerless to protect the body against Meanwhile The Normal Heart bases its medical it. Why? We don’t know. The body’s immune sys- viewpoint on the relationship that its main char- tem ceases to function. [It would be more correct acter, Ned Weeks (Mark Ruffalo), establishes with Doctor Emma Brookner (Julia Roberts). Brookner to say it gets weaker.] Sometimes the body even uses a wheelchair, having suffered from polio as attacks itself. [In fact it is the virus that weakens a girl. For this reason she empathizes with the the immune system.] At any rate, it’s left open to impotence her patients feel. However, the doc- a whole horror house of infections from microbes tor is an exception in the TV movie. At a time it usually defends against. [ … ] We think it may when the immune system was “a real unknown” also be able to slip past the blood-brain barri- and the transmission routes of the disease were er into the brain. Which is, of course, very bad unknown, many doctors refused to see patients news. It’s fatal in we don’t know what percent of because of a fear of contagion. “They turned us people with suppressed immune responses. [ ... ] away from four emergency rooms,” says a friend The NlH in Bethesda has a new drug called AZT of Weeks one night when he turns up at his home with a two-year waiting list that not even I can get with his boyfriend passed out in his arms. you onto.” In another scene, Weeks visits a hospital where several patients have been hospitalized Prevention and transmission routes because of the “gay cancer”, and where numerous posters warn him that he is entering a “conta- “Do you think that this cancer is sexually trans- gious area”. When he asks about the lunch trays mitted?”. “I think it is, yes. Can I prove it yet? No.”

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Medicine in Television Series

Through this conversation in The Normal Heart, doctors refuse to examine him for the cause of Doctor Brookner asks Weeks, a renowned and death. Because there is no death certificate, the polemic writer, to try to convince the gay commu- undertakers and police will not come, so the de- nity to stop having unprotected sexual relations. ceased’s boyfriend and mother pay 50 dollars to His efforts with a generation blinded by the ide- a hospital attendant to remove the corpse from ology of sexual liberation, one which took them the hospital and they transport it in their own car. so many years of struggle to attain, are in vain. Once at the funeral home, they are forced to pay “The entire gay political movement is fucking,” he 3000 dollars to collect the deceased’s ashes. says. “Guys will become frightened of sex. They In Angels in America, social acceptance of the will lose our self-respect, that we fought very, very disease has progressed very little. When the doc- hard for.” Brookner’s discourse, moreover, loses tor tells Cohn his diagnosis, they have the follow- force from the moment she cannot even assert ing conversation: that the infection is sexually transmitted. − COHN. This disease… Later it was shown that infection was con- − DOCTOR. Syndrome. tracted through blood, sexual relations and − COHN. Whatever. It afflicts mostly homosex mother’s milk. Drug addicts, from sharing used uals and drug addicts. syringes, hemophiliacs, through contaminated − DOCTOR. Mostly. Hemophiliacs are also at risk. blood transfusions, and MSM, due to the nature [ ... ] of their sexual relations, were the first population − COHN. And what is my diagnosis, Henry? groups affected. However, the infection was also − DOCTOR. You have AlDS, Roy. transmitted in heterosexual relations. In fact, at − COHN. No, Henry, no. AlDS is what homo- one point in The Normal Heart, Brookner states sexuals have. I have liver cancer. that “Women have been discovered to have it in Africa, where it is clearly transmitted heterosexu- So Cohn is stating that the version he will ally”. make public regarding his state of health is that he has liver cancer, since he cannot admit he is suffering from a disease attributed to homosex The stigma uals. If he did, he fears he would lose all his pow- Social rejection is doubtless the most difficult hur- er and influence. dle to overcome for characters in both fictions. Nobody knows where the disease comes from, A lack of support not even the homosexual community itself, which from the public authorities in The Normal Heart even points to a possible “conspiracy to murder all gay men”, or ques- The Normal Heart also shows the fierce struggle tions “monogamy” as a possible cause of infec- the activists take on to achieve social and finan- tion. Outside of their community, things are much cial support from the public authorities. For ex- worse. They have problems even hiring a venue ample, it took the GMHC 14 months to gain a for their association, the Gay Men’s Health Cri- meeting with the mayor of New York, and in the sis (GMHC), and one of their members is warned end, he did not show up to the meeting. When, that, if it came out that he belongs to it, his job at some time later, they receive financing from the the Department of Health would be at risk. council, they are given strict instructions not to The toughest situation, however, arises when say where it came from. The justification that a friend of the protagonists travels to Phoenix Weeks receives from the council is: “I don’t think (Arizona) with his boyfriend to visit his mother be- we can afford to make so many enemies.” fore death. The pilot of the plane refuses to take From the White House, the only attention they off when he discovers there is an AIDS sufferer receive is from one of the president’s advisers on board. When, thanks to another pilot, they fi- who, once in the meeting, makes it clear that his nally arrive, the young man dies and the hospital sole interest in the meeting was to find out per-

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sonally whether the infection can be transmitted on the disease’s social aspect. One of its objec- between men and women. Weeks, beaten, can tives was, precisely, to destigmatize the disease only answer that, though he cannot guarantee it, and distance it from prejudice. in theory, the affliction seems only to affect the Its main characters are two women who are homosexual community. carriers of the virus, but very different to each For her part, Doctor Brookner also maintains other. Vero (Montse Germán) is a well-to-do her personal crusade to ensure that study of the graduate of around 38, who seems to have nor- disease receives government funding. She ac- malized her illness among her friends and inner cuses the government of spending more mon- circle. She does not tell everyone she meets, but ey on “investigating seven deaths from Tylenol” neither is she ashamed of her status, and she (a drug whose active ingredient is paracetamol) seems to lead a happy life. In contrast, Gloria than on HIV, and of refusing to cooperate with the (Mercedes Sampietro) is a woman over 60, from French to “steal a Nobel Prize”. a low socio-cultural level, who keeps the disease The allusion to the dispute for the Nobel Prize an absolute secret. She lives with her son Rober is not anecdotal. The virus was isolated for the (Roger Coma), who is likewise unaware of his first time in 1983, by investigators at the Insti- mother’s status. Both women only meet the odd tut Pasteur in París. Virologist Luc Montagnier’s time during the film, in hospital, and in the NGO team identified a new class of human retrovirus, where they both seek shelter. and indicated it was the cause of AIDS. Mon- The TV movie starts with a birthday celebra- tagnier sent samples to the American virologist tion, bringing together ex-students from Vero’s Robert C. Gallo, who confirmed that HIV was university days after 20 years. This is where Vero the cause of AIDS, and helped develop the meets Xavier (Pau Durà) again, and everything blood test to detect it. Nevertheless, the 2008 she thought she had under control comes tum- Nobel Prize for Medicine was awarded to Mon- bling down. Xavier has just separated from his tagnier and the French virologist Françoise wife and has a son, but the passion and love Barré-Sinoussi. Gallo had confirmed the link of between them reignites immediately. In their first HIV with the disease, but the French were the sexual encounter, Vero does not tell him she is first to isolate the virus. HIV-positive because she thinks that, since they The Normal Heart finishes in 1984. The final use protection, it is unnecessary. We then see credits explain that Reagan did not mention AIDS how, on successive occasions, they always use in public until 1985, when he promised that re- condoms and she becomes increasingly con- search against the disease would have “maxi- cerned about the situation as her relationship mum priority” and that 126 million dollars would develops and she starts falling in love. Finally, be earmarked for it in 1986. The film denounces urged on by her best friend, she decides to talk that this figure was reduced to 85.5 million, an to him. This is a key scene: a conversation lasting insufficient amount to cover the costs of a pan- over ten minutes that develops into an emotional demic that, by the end of that year, had caused roller-coaster between the two characters. For 24,559 documented deaths in the US. Vero, it is clear that the fear and anguish hold the same weight as the need to communicate (it has taken several weeks for her to feel strong enough The case of Positius to take this step). Xavier, for his part, starts by In Catalonia, the disease has occasionally ap- listening understandingly, but little by little his face peared in many TV series, though few produc- transforms from “apparent understanding” to “ut- tions have had HIV as their central theme. In con- ter panic”. He does not understand how she trast, the TV movie Positius, produced by Ovideo could hide something so significant, which dir for TV3, written by Aina Clotet and Álex Mañas, ectly affects him. Meanwhile, Vero does not stop and directed by Judith Colell, did place the dis- repeating that she “has always protected him” ease center stage in the script. The story focuses and that she “needed to feel safe with [him] in

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Medicine in Television Series

order to share [this knowledge]”. The scene lets Conclusions viewers share and understand the fears that this Analyzing all three productions, we can see that disease entails: fear of rejection for the sufferers, they all practically repeat the same concepts: and fear of contagion (often the result of massive disinformation, lack of prevention, stigmatization disinformation) in the case of the sexual partner. and scarcity of resources from the authorities to The scene comes to a tragic end for both, ter- fight against the disease. minating with Xavier’s exit, leaving Vero broken In the twenty-first century, AIDS continues to and alone. be a reality among us. Nowadays, thanks to the In contrast, Gloria, the other protagonist, huge advances made in recent years, we can gets a job offer to look after the daughter of chronicle the disease, but at an untenable long- Belén (Aina Clotet). Gloria’s lack of education term cost for public health, and with a certain and knowledge cause her to make excuses and toxicity for the patient. turn the job down, afraid she will infect the girl Science is progressing in great leaps to cure just by contact. Worried, Gloria goes to visit an AIDS in infected sufferers. Research seeks to NGO (pretending she has an HIV-positive friend), eradicate HIV from the organism so that lifelong where finally they inform her and help her under- treatment becomes unnecessary. Highly prom- stand that she “cannot infect anybody just by ising therapeutic vaccine models exist, which, touching them”. In the end, Gloria is able to ac- combined with other strategies, will lead to a cure cept the nannying job and the relationship with for the infection. The foremost laboratories world- the little girl becomes increasingly closer until the wide have set the goal for achieving it in 2020. girl becomes her reason for living. Unfortunately, But until this occurs, AIDS remains a reality. The Belén ends up finding out that Gloria is HIV- stigmatization has not disappeared, but young positive. With no explanation, she immediately people live “as if it didn’t exist”, leading to a fresh forbids her from seeing her daughter. Gloria falls peak in cases. In these moments of crisis, when into a deep depression, goes off her medication resources are increasingly limited, we have to ex- and is admitted to hospital. It is Gloria’s son, who tend the concept of “corporate social responsibil- until that point had seemed a distant figure and ity” not to apply just to companies, but to people did not know about her illness, who becomes individually. If each of us do our bit, we can help her greatest support. to end this pandemic.

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Notebooks of the Esteve Foundation Nº 42

Nip/Tuck, Grey’s Anatomy and Plastic Surgery

María del Mar Vaquero Pérez

Both productions could be considered to be the launching pad for two meteoric careers: producers Ryan Murphy and Shonda Rhimes. Today they are two television industry heavyweights. The former sprang to fame in 2003 with Nip/Tuck, a polemical vision of plastic surgery, shown through the lives of its two controversial protagonists. Along with The Shield, this program brought the cable channel FX into the orbit of series addicts. Years later, he would again work for this channel on American Horror Story. Shonda Rhimes’s career took off in 2005 with Grey’s Anatomy, which still keeps audiences in their millions glued to the screens of free-to-air channel ABC. Its success has enabled the channel to open a production company for TV series (Scandal, How to Get Away with Murder), now dubbed Shondaland.

It might seem obvious to begin this chapter profession, meaning they share the suffering and dedicated to plastic surgery in TV series by men- recovery of the sick. There are stories of interpret- tioning the fascination that doctors’ private and ing the patient’s death as a personal failure, or as professional lives have always held for viewers. proof of the uselessness or insufficiency of their Every aspect relating to medicine, to the work knowledge. And even –why not?– stories of the and coexistence of health professionals in that doctor who acquires more of a human dimen- independent city that a large hospital constitutes sion when he or she switches roles and becomes are fertile content. Such aspects include the dra- a patient. This is a fascinating viewpoint, which matic change of lifestyle a disease’s appearance portrays how difficult it is to take (as the saying brings about, but also the analysis of symptoms, goes) one’s own medicine. like clues in a mystery movie, that lead to uncov- Medicine in film has given us marvelous stor ering the diagnosis of an illness. Witnessing the ies in every imaginable genre and setting. We progressive deterioration of a character suffering have seen doctors starring in romantic mov- from a degenerative disease, or –let us say it– the ies and who, prompted by love, seek a cure for moment of death itself, all of these are excellent their loved one. Or else they end up falling in love storylines for thousands of scripts. They contain with the patient they cure. In war movies of any enough elements of tragedy, drama, anecdote period, doctors often battle with few resources and human overcoming of challenges to attract but enormous inventiveness. In natural disasters viewers. or epidemics, they lead the survivors toward a The permanent contact of doctors with life, new dawn. In crime films, they reveal the best suffering and death make them the ideal heroes of a little-known specialization such as forensic in many stories. These include both their own medicine. There are innumerable stories more. It and those resulting from their professional voca- is tricky to find a medical specialization that has tion, which sometimes leads them to sacrifice not been dealt with on the silver screen. personal or family life. Similar are the stories of As if this were not enough, as series devel- their involvement with family members and pa- oped, TV let viewers get to know the doctor tients, stories of the empathy inherent in their starring in a storyline, and to share his or her de-

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velopment and dénouement. Furthermore, view- understands what a plastic surgeon may do in ers could partake of the professional’s daily life his practice, he focuses on his facet as a creator in each episode, experience the adventures that or recoverer of beauty as the sole thing that holds so attracted them one after another. With every interest in fiction? Or is it that plastic surgeons weekly broadcast of her or his work, they shared ourselves have not known, been able or wished his or her achievements, failures and affections, to demystify that image that portrays us as the against a backdrop of recovery, loss, overcom- most enviable of stars? ing odds, frustration, life, and even death. Medi- The answer is surely a combination of all of cal television series have encouraged more than this. Though there are few, if barely any, posi- a few professional vocations, increasing student tive examples we can point to of this special- numbers in medical faculties, attracted by the ization on-screen, we will at least aim to reflect daily adventure of this profession. real knowledge of the specialization and try, by I think this reminder is apt so as to be aware demystifying the stereotype, to reveal the true of the scant treatment of equal depth and con- importance of what plastic surgery and its practi- tent the specialization to which we dedicate this tioners offer patients and the other medical spe- chapter –plastic, reconstructive and aesthetic cializations. surgery– has received in film and TV. I know some people would say that this is not so. We A little etymology and history are used to seeing stars undergo changes in appearance. It could be so an actor can replace a Plastic, reconstructive and aesthetic surgery. This colleague in a long-running series without altering is a long name for a broad medical specializa- the storyline or the central characters in the plot. tion which is nevertheless most often abbrevi- Or maybe the character has a serious accident, ated to plastic surgery. It is, furthermore, wrongly or survives an assassination attempt that disfig- associated with just half of its content: aesthetic ures him or her, and must return with a fresh face surgery. This would be understandable in the to take revenge. These are recurring themes on- context of the broader public. However, it is un- screen. This is undeniably true, and is no doubt fortunately also the case among many medical the first notion that pops into our mind regarding professionals, who remain ignorant of everything plastic surgery. Yet outside of this easy script re- this specialization encompasses and the services source –a rather surreal concept reflecting none it can offer. Let us look more closely at them. of the reality of the specialization– what does the Plastic, reconstructive and aesthetic surgery broader public know about what plastic surgery is the medical and surgical specialization con- consists of when given its full name: plastic, re- cerned with correcting any congenital, acquired, constructive and aesthetic surgery? How has tumorous, or simply regressive process requiring TV fiction portrayed this specialization in series repair or repositioning, or which affects bodily on medical themes? Have the fictional charac- form or function. Its techniques are based on ters approached the plastic surgeon’s image as transplanting and mobilizing tissues using grafts a doctor with the same dimension as a health and flaps, or even implanting inert material. In its professional as has been fomented for other spe- most recent advances, it also employs complete cialists? units of donor tissue, such as limbs (arms, hands, Frequently, plastic surgery and its professional legs) and the covering of the face. practitioners only inspire frivolous plotlines or em- The full content of plastic surgery encompass- body characters lacking the basic ethical prin- es two fields of action. The first is reparative or ciples that govern the doctor-patient relationship. reconstructive plastic surgery. It seeks to restore Is this the fault of scriptwriters who are ignorant of or improve the function and physical appearance the specialization’s content or the fields of inter- of injuries caused by accidents and burns, in skin est it comprises? Or is it a deviation from reality diseases and tumors, along with the tissues be- that means that, though the scriptwriter perfectly neath the skin. It may correct congenital anoma-

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Medicine in Television Series

lies, mainly facial, or on the hands or genitals, or scribed to reconstruct the nose, which is known else anatomical defects caused after an onco- as an Indian flap. logical surgical resection. Then there is aesthetic Yet no doubt it was World War One (1914– or cosmetic plastic surgery, which treats gener- 1919) which caused plastic surgery to develop ally healthy and emotionally stable patients. Such as a specialization. A huge number of soldiers surgery makes alterations that, while not con- were wounded by shelling and burns, as a result stituting pathological processes in themselves, of which their bodies and faces were disfigured. cause a deterioration of health to the extent they So professionals had to be trained and medical interfere with people’s physical and psychological centers specialized in surgical reconstruction wellbeing. So its aim is to correct differences from created, both in Europe and the US, where this aesthetic standards or the effects of ageing. specialization was not recognized. It remained A plastic surgeon, to use his or her shortened more or less associated with maxillofacial surgery title, may be concerned with repairing congenital for many years. Then in the Second World War malformations, treating and operating on burn (1939–1945), plastic surgery’s field of activity was victims, reconstructing any anatomical defect, expanded and it began to appear as an indepen- carrying out surgery by hand, conducting micro- dent specialization. Dr. Archibald McIndoe devel- surgery, re-implanting or transplanting limbs or oped (what for the period were seen as strange) faces, and performing aesthetic surgery. From transfers of healthy tissue to damaged areas, head to toe. In the words of Dr. Raymond Vilain, using pedicle flaps. These enabled many avia- the plastic surgeon is, in fact, “the last general tors who had been disfigured by fire to abandon surgeon”. the isolation to which they had been condemned Concerning the name’s etymology, “plastic” as monsters. Medicine had certainly saved their stems from the Greek plastikos, which means lives, but at the cost of depriving them of employ- to mold or transform. So in its entirety, plastic ment or social life in the community, and leading surgery is aimed at aesthetically designing bod- in the worst cases to suicide. So McIndoe’s in- ies through remodeling to improve them, what- novation thus lessened their suffering, reincorpo- ever the reason for surgery, or to make them rating them into acceptable social and aesthetic more beautiful. The plastic surgeon acts thus. norms. She or he seeks harmony, beauty and adapta- The Spanish TV series Canal Historia and tion to aesthetic norms and functionality. This is Odisea offer episodes on Dr. McIndoe, using pe- independent of that separation into two activity riod photos and the real voices of the veteran fields, which is demarcated, in fact, by society protagonists themselves to tell the stories of the and health systems (public healthcare and private young pilots in the Allied air forces he treated. insurance companies), which thereby attempt to When their bombers, loaded with large amounts limit the coverage of care intervention costs. of highly inflammable fuel crashed, the aircrew It is not just etymology that unites the func- were consumed in huge blazes, from which they tions of plastic surgery but also its documented occasionally managed to escape alive, though history. Both the Edwin Smith Papyrus from with faces and bodies totally charred. Survival Egypt (3000–2500 BCE, according to Breasted’s was a goal, but afterwards, tortured by their ap- studies) and the Sushruta Samhita (“Suśruta’s pearance, they needed their faces and hands to Compendium”) from India (500 BCE) document appear and function more or less normally again. nose reconstruction. In that period the nose and They wanted to feel like accepted members of that ears were considered to be appendages convey- society which, while respecting them as heroes, ing reputation and respect. So it was common to shied away from their disfiguration. Many were amputate them as a punishment against crimi- between 17 and 21 years old. Thanks to Dr. nals and defeated peoples. Rewards were even McIndoe’s innovative techniques of the time, paid for every nose and ear delivered. Even now- these men tell how the correction of their dis- adays we still use the frontal flap Sushruta de- figuring became a virtue. McIndoe founded

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his Plastic and Maxillofacial Surgery Service at facets of medical practice. These are developed Queen Victoria Hospital in the village of East in contrasting environments, for likewise dissimi- Grinstead, Sussex, England. Here, people got lar purposes. They are even undertaken by sepa- used to seeing and accepting his patients on the rate medical professionals. street, in local pubs, and even in London itself. They would carry their pedicles like small trunks TV fiction and plastic surgery that transferred tissue from their abdomen to the arm, from there to the shoulder and then to To move on from plastic surgery’s noble and his- the face, finally becoming a new nose, cheeks torical facets to analyze its evolution in TV series or chin. During the time this process lasted, the involves a search. However, we find little mate- patients and those around them saw how these rial worthy of mention, because as far as I can disfigured faces were gradually conforming to a recall and trace, few TV series, whether on medi- normalcy accepted by all. cal themes or not, include a character having The patients who lived there, sometimes for this specialization. Perhaps the most famous in three to four years, and underwent 20–30 opera- recent years are doctors Sean McNamara and tions, managed to save not just their lives but also Christian Troy in the series Nip/Tuck, and doc- their minds thanks to plastic surgery and Dr. Mc- tors Mark Sloan and Jackson Avery in the series Indoe’s approach and psychological work. Sev- Grey’s Anatomy. We would like briefly to pres- eral ended up marrying the nurses who cared for ent these series to those viewers who have not them. They even formed a club, The Guinea Pig watched them, or who have heard of them at Club, which over its more-than 60 years of his- some point but do not know them well. tory brought together over 650 members. Years Nip/Tuck was a series that aired from July later, its survivors and their descendants continue 2003 to March 2010 on the American cable TV to meet to honor their “creator” and raise a few network FX Networks. It ran for six seasons and is pints to him while singing the anthem they com- considered an innovative TV product for its time, posed in his name. The light-hearted lyrics go: because of the subject it tackles and because “We are McIndoe’s army, it gave the language of TV series a filmic style. We are his Guinea Pigs. Classified as a drama series, it won the Golden With dermatomes and pedicles, Globe for best in its category in 2005. Already, Glass eyes, false teeth and wigs. in 2004 it had won an Emmy from the US Na- And when we get our discharge, tional Academy of Television Arts and Sciences We’ll shout with all our might: (NATAS), for Outstanding Prosthetic Makeup for Per ardua ad astra [“Through adversity to the a Series. stars”] The storyline follows the life and work of two We’d rather drink than fight…” plastic surgeons, Dr. Sean McNamara, played Knowing all this inevitably leads one to reflect. by the actor Dylan Walsh, and Dr. Christian Troy, It is odd that both the early plastic reconstruc- played by Julian McMahon, who run a private tions described in written historical documen- clinic first in Miami before moving to Los Angeles tation, and the main milestones leading to the to set up their practice in Hollywood. creation and development of plastic surgery as In the series, these professionals’ qualifica- a specialization, linked the components of ma- tions and practice is in fact merely an excuse terial, functional and aesthetic reconstruction so to explore one of the most polemic subjects on intimately as a basis for a person’s social accep- American television through the self-destructive tance and reincorporation into society. Yet nowa- nature of its characters, true both of the starring days, it is customary to observe how society has doctors and their patients. Furthermore, it dealt generally separated the aesthetic and recon- with topics that were not habitual on the medium structive elements into two clearly differentiated or in the US, such as drugs, abortion, homosex

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uality, transexuality, sects, personal ambition and were operating, talked about their personal lives, the constant search for pleasure and money. It relationships, families and hobbies, even their portrayed a lack of personal or medical ethics, money worries –all the while opening up and cut- and depicted lives dominated by envy, stress, ting into their patients’ bodies. lust and even crime. All of this doubtless earned it So these two TV series, with quite different significant criticisms from more conservative sec- takes on medicine and doctors, were both hugely tors, both in the US and other countries where it successful and on air for a long time. By focusing aired. on characters who are plastic surgeons, we will Grey’s Anatomy is a medical series from the elucidate how they portray this discipline in TV US network ABC, which began in March 2005 series. Does the educational tone and appeal for and is still on air. It takes its name from the re- the wider public, which every TV show strives for, nowned treatise on human anatomy, Henry manage to convey a faithful or at least realistic im- Gray’s Anatomy of the Human Body, better age of plastic, reconstructive and aesthetic sur- known as Gray’s Anatomy, a basic textbook for gery? Do they portray the lives and professional training US medical students published in 1958 dedication of these specialist practitioners? by Henry Gray. So it plays on his name and Dr. Meredith Grey’s, the series’ central character. The plastic surgeon: hero or villain? It won a Golden Globe for Best TV Drama Series in 2006 and has garnered a total of 38 nomina- In its time, Nip/Tuck was startling for its care- tions for the Emmy Awards in different catego- ful aesthetic, apparent right from the slickly ries (script, actors, direction, etc.), of which it has designed opening credits accompanied by its won four further awards. theme song, Engine Room’s A Perfect Lie. Since The series is set in Seattle Grace-Mercy West the credits and theme song are brief, we are Hospital, tracing the professional development of plunged into the atmosphere in which the story different medical specialists whose lives cross the will develop: aesthetic surgery. The discipline, protagonist’s. The series viewpoint is interesting by cuts and stitches, can recreate those perfect because it focuses on the life and hopes of the bodies –represented in the credits as cold, iden- resident medical interns who join the hospital to tical, beautiful but static mannequins without life train as future specialists. There is tough compe- or personality, and still semi-packaged– while the tition between them, but also passion not only lyrics croon: for medicine as a profession but for the value of “Make me beautiful, patients’ lives. A perfect soul, For the subject concerning us, we look at two A perfect mind, characters who, while they began as guest stars A perfect face, (conceived as occasional appearances in specific A perfect lie.” episodes), gradually gained prominence and became part of the core storyline, essential for the At first, it seems viewers are being offered the series’ development. They are Dr. Mark Sloan, same view as ever –beauty as little more than played by Eric Dane, and Dr. Jackson Avery, an end. Yet patience will reveal more. Its central played by Jesse Williams. characters are two plastic surgeons specializing Series creator Shonda Rhimes seems to have in aesthetic surgery who have been friends since conceived a fiction that offers a voice to intelligent youth. As we mentioned in the introduction, “aes- women who compete with each other. To do so thetic” and “reconstructive” are two medically in- she devised a medical setting based on the im- separable facets. Aesthetic, like reconstructive pression she got when over a period she became surgery, rebuilds bodies and fortifies minds. From obsessed, along with her sisters, with watching this viewpoint, the series seems to promise to surgical operations on the Discovery Channel. center on one of the few branches of medicine She was surprised that the surgeons, while they excluded from any health policy, since it covers

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content that is not considered vital. It would even patients want to do with their bodies. Even if seem a good idea to publicize aesthetic surgery Dr. Frederik McLorg defined the specialization as as something that is not limited to artists or mil- “a surgical discipline that resolves problems”, we lionaires. It would be beneficial for viewers to also said that aesthetic surgery treats healthy and know what can be done for patients to feel good emotionally stable patients. But the truth is, none about themselves and in their surroundings, to of those on Nip/Tuck seems to be so. Added to overturn myths and, somehow democratize ac- this, with every episode, the personal storylines cess to the specialization. of the main characters get increasingly tangled. The program starts in the consulting room of When the whirlwind of their lives careers into a doctors McNamara and Troy while the lights go labyrinth of personal perversions and criminal on in corridors, waiting and recovery rooms, and underworlds in which no averagely conventional in the operating theater. They reveal a blend of situation appears ever to have existed, or which clinical setting with the most spectacular, inno- could not be found in other crime series that do vative decor imaginable, where elegance and a not need a medical setting, the series starts to five-star air predominate. It is a vision in which, head rapidly downhill, especially in the final three furthermore, a fast change in tempo have us seasons, until its demise became inevitable. abruptly suspecting that the entire medical at- Why did the scriptwriters choose that profes- mosphere will be nothing but glamor. It seems sion and that surgical setting to present two such vile and tormented characters? It is difficult to we will be watching the same sort of program as know, but I believe it was thoroughly unneces- always: will it end there, as usual? sary. Do they contribute anything to our aim to Dr. Troy is attractive, sexy, single, a woman- see if aesthetic plastic surgery appeared for the izer, narcissistic and a less-brilliant surgeon than first time as a central theme in a television series? his partner, though he is an excellent public rela- Personally, I do not think so. On the contrary. Be- tions man. Dr. McNamara is less attractive, mar- yond what could be an attempt to shine light on ried with three kids and the better surgeon of the certain themes that also fall within the sphere of two. Following the traditional, “good cop/bad this specialization (surgery on transsexualism, the cop” setup, Troy is the dark side while McNamara effects of morbid obesity and little else), the rest represents firm convictions. is the same as always: scars that appear to van- Thus, the premise is set up and the story be- ish as if by magic, body remodeling carried out gins, with episodes that each bear the name of using liposuction, and surprisingly fast recoveries the patient operated upon as a central theme. after surgery. Nevertheless, they try to give a feel- And at the beginning of each episode, the doc- ing of authenticity by introducing intra-operative tors always ask the same question: “Tell me what shots of cuts, visible wounds, blood, fat that is you don’t like about yourself”. It is a good line, but extracted in buckets from patients’ bodies, and too simple and even risky for initial intercommu- so on. All of this panders to the morbid fascina- nication with the patient in a consultancy of this tion of viewers, watching with divided attention type. The problem gets worse, moreover, when while eating dinner. In the end, nothing different we observe that none of the patients seems to or of value occurs to reveal the positive side of present problems or pathologies typical of a plas- aesthetic surgery or to portray it in a realistic way. tic surgery consultancy that might be called con- Even the patients who seek to recover their faded ventional. Each patient is increasingly strange or beauty or youth fall into addiction, seeking sur- unhinged. This confirms our initial fears. In fact, gery as their sole form of survival and showing the series opts to portray the frivolous side of the the most disastrous image possible to viewers. specialization. I would say it is quite unreal and The surgeons operate without masks, mak- even illegal on many occasions. ing surgery seem simple and easy while calcu- A plastic surgeon who undertakes aesthetic lating their profits. A mini-bar is on display in surgery is not the “achiever” of everything his the consulting room, while the doctors’ coats

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are not even white but a strange tone of blue to narrator tells us how in 1987, after the infamous match the decor. The doctors immediately lead Black Monday crash, a new financial golden age their conversation with patients into personal ter- was born, and along with it, a new industry, the ritory. They insinuate or leave the field open for luxury industry. Newfound wealth coupled with their female patients to make sexual insinuations easily available credit opened the door to vani- in the consulting room. Are these doctors differ- ties and excesses once reserved for the rich and ent to others, or are they making an effort not to famous, among them, plastic surgery. The “new seem like doctors in front of their patients? This must-have status symbol” was a perfect body. is what happens when one wants to convey the In this narrator’s words: “compliant thighs and ti- idea that plastic surgery, at the end of the day, tanic tits”. At that money-earning peak of offering is not medicine or even surgery. One should not both the possible and unattainable, McNamara scare the patients. This goes beyond a doctor- and Troy rub their hands at the profits they earn patient relationship, into commercial territory, with each patient. They enlarge their consultancy, trivializing an operation’s risks, or pretending that furnishing it in luxury, and spend endless amounts the patient’s wishes must be served at all costs. on cars, yachts and the high life, thereby marking We even wonder why plastic surgeons on-screen their professional status in a medical specialization kiss their patients goodbye instead of offering a very different to others. It seems to allow plastic friendly but respectful handshake. surgeons to earn huge sums of money very eas- Leaving aside detective-style plots and situ- ily. No stress can be seen during surgery. They ations that are far removed from these plastic merely tote up their earnings for each operation. surgeons’ professional practice, we might even Yet when this fairytale ends and the international accept some degree of rivalry between col- credit crunch hits, the operations decrease drasti- leagues, professional jealousies, or even some cally as do their earnings. It is tough to maintain small stratagem to become the patient’s favorite. the world they have created, and even tougher to These things might be seen to a certain extent appear to be doing so. This is where the financial typical of medical competition and the quest for stress seems to turn these doctors human, and professional excellence. Viewers might even for- they start to feel anguish and stress they have give them such striving after perfection that ev- never shown in the operating theater. ery plastic surgeon carries inside. Not in vain did Are they a special case? Unfortunately, for the even Dr. McIndoe, mentioned in the introduction, series creators it seems not, because when an- say that in his work he felt God’s presence de- other colleague joins the firm for an episode or scending into his right arm. But doctors McNa- a season, we assume either “birds of a feather mara and Troy take all this to the limits of deceit, stick together”, or that the scriptwriters do not jealousy and destruction. Neither do they seem appear to believe anybody can practice this spe- to have much empathy with their patients. Some- cialization with a modicum of ethics or medical times they even clearly make fun of their com- professionalism. For example, in the first sea- plexes. McNamara, though we noted he is firmer son, Dr. Merril Bobolit, played by Joey Slotnick, in his personal convictions in early episodes than showed fewer scruples than the central charac- his partner, allows himself to be swayed in the ters and is able to undertake illegal operations, quest for the only goal his consultancy pursues: continue operating after losing his license and money and success at any price. Troy, who use anesthetic gases as a drug. Generally, any adores female bodies so much for his own plea- other plastic surgeon who enters McNamara and sure, creates beauty in his patients so as to then Troy’s consultancy is the same. They all seem to seek sexual relations with them. He is, moreover, link their profession to a disproportionate quest profoundly misogynistic, scorning and mistreat- for fame and money, and to a total lack of scru- ing women. ples to achieve them. What is interesting at the time of writing is Beauty, success and money seem to be the the sixth season’s opening episode, in which a ideal in plastic surgery, at the hands of handsome

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young doctors like Dr. Troy, who throw out lines hold for the residents in training at Seattle Grace like “Appearance is everything”, “Beauty is hap- Hospital. They generally refuse to participate in piness, beauty is power, beauty is confidence”, surgery with Sloan while they fight energetical- or “Going against established beauty is to ignore ly to attend, even just to observe, in any other the world in which we live”. When these ideas are specialization’s operating theater. Is this a subtle stirred into such a risky fictional cocktail, I firmly way of saying that what plastic surgeons do is believe this reflects poorly on the reality of plastic not important? Is it a secondary specialization surgery. According to such tenets, this profession to choose to learn? Dr. Sloan is hard-pressed does not merely implicitly espouse the cause of to attract any resident who wants to follow his money and success for surgeons and patients, work, and when he does find someone, he in- but also flouts it ostentatiously. So these profes- vites them to participate not in his team but in sionals forget the aims on which the practice was what he calls his Plastics Posse, to the embar- founded, the work of its pioneers, and everything rassment of the resident selected, who sees no the practice can achieve, not just in aesthetic sur- special honor in it, rather a means of removing gery but in collaboration with most other special- them from true surgery. This is a curious view- izations in a large hospital. point, since in Spain, for example, the special- Despite Nip/Tuck’s success –more closely ization of plastic, reconstructive and aesthetic linked to its slick photography, morbid fascination surgery is every year more in demand by re- with excessive hyper-sexuality and the introduc- cently graduated doctors who have passed the tion of extreme themes– it does not help at all MIR exam (for Resident Intern Doctors). Training to present the reality of plastic surgery. Rather, places are quickly occupied by students with it completely distorts its governing foundations the best academic records. while promoting the most fictitious and unreal It is a shame that in this series too, what is stereotype of plastic surgery specialists. Medi- sometimes seen as a small glimmer of recogni- cine and the specialization operate as a mere tion toward the discipline of plastic surgery, or excuse in which to set the storyline and increase of publicizing the specialization’s novel and in- the morbid excitement of their patients’ increas- teresting aspects, ends up being lost in the ba- ingly extravagant requests. nality of the character of the plastic surgeon. He In narrowing the search for more appropriate seems friendly, but is never a leader among his sensitivities to the plastic surgeon’s work, there colleagues who have other, better recognized is more joy in the treatment given to the special- specializations. He ends up once more being ization in Grey’s Anatomy. The program’s plastic the good-looker, scorned and superficial, who surgeon is Dr. Mark Sloan. Though we might ex- easily performs less important operations. With- pect little from a plastic surgeon who, predictably out have taken advantage of the whole range of following the jaded stereotype of TV fiction, is options the specialization might offer in a series the most attractive doctor in the hospital, and such as Grey’s Anatomy about a large hospital, is dubbed by his female colleagues “McSteamy”, Dr. Sloan, who first appeared in the third season, in some episodes he represents plastic surgery’s was dropped from the series in the ninth. contribution much more faithfully. In the series we His place was taken by Dr. Jackson Avery, see cases of facial reconstruction after traffic ac- the only surgical resident who became Sloan’s cidents, micro-surgery, reimplants and children protégé, and to date he seems to uphold the with birth defects. Dr. Mark Sloan’s work includes moral values and medical practices common to far more than just aesthetics. It seems the pro- the other specialists. At some point it is revealed gram wants to introduce us to plastic surgery’s that his choice of plastic surgery may have been more useful side, including collaboration with consistent with his good breeding. Not for noth- other specializations. ing is he the grandson of one of the country’s However, it does call attention to the lack of most reputable surgeons. His family owns an im- attraction that the surgery he conducts seems to mense fortune, thanks to which they are patrons

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of one of the country’s most significant medi- pursues. The surgeon’s experience and skill are cal prizes. Nevertheless, he seems to maintain fundamental, but possibly more than in any other a straight professional path while, like Sloan, he specialization, a connection with the patient is tries to attract one of the new residents to the fundamental in order to recognize the latter’s ex- Plastics Posse. Such sound professional judg- pectations and offer her or him the most realistic ment by Dr. Avery seems to have shrunk his solutions, or to know when to refuse if such ex- participation as a specialist and the presence of pectations are unrealistic or unhealthy. The plas- pathologies typical of his specialization in the se- tic surgeon must get inside his or her patients’ ries. Meanwhile, given the show remains on air, minds, recognize body dysmorphic disorders we hope for plastic surgery to feature once more and help patients to see that, to paraphrase the on the small screen at some point. And if not French mountaineer, photographer and filmmak- portraying it better, at least it may have the same er Louis Audoubert: “As far and wide as we travel degree of reality, professionalism and interest as the world seeking beauty, we will never find it un- the other specializations. Perhaps Dr. Avery will less we carry it with us”. manage to attract one of the many female doc- It is true that private exercise of the specializa- tors starring in the series into his specialization. tion enables plastic surgeons to develop a more This would shatter another myth that only men lucrative professional activity since aesthetics is work as plastic surgeons, above all in aesthetic one of the few medical activities that falls outside surgery –a specialization belonging to men who of health coverage and health insurance. But sculpt beauty in women. There is scant need to this does not make plastic surgeons mere skillful recall the current growing dominance of women businesspeople trading on their patients’ health in medicine, in Spain and worldwide. In this sec- at any price. We should not allow the superficial- tor as in others, reality takes one path while fic- ity of the image that to date has predominated in tion takes another. A woman surgeon in the con- film and TV fiction of plastic surgery operations. sulting room would not perhaps offer so much Nor should the model of its professionals obscure morbid fascination when creating storylines and the reality of a magnificent specialization that ful- less dramatic play in episodes. So would only fills in its deepest sense the definition of health the professional viewpoint remain? Would there established in the Preamble of the Constitution of not be so much room for parallel storylines of sex the World Health Organization: “a state of com- and fast cars? Perhaps the resulting character plete physical, mental and social well-being and would be too boring. not merely the absence of disease or infirmity”. Yet it is not just film and television that should convey that image. Plastic surgeons themselves Conclusions are responsible for this image we present to so- As Gaspar Tagliacozzi, one of the pioneers in ciety and to make our practice a reflection of our plastic surgery in the Medieval period, wrote in professionalism, undergoing constant training his work De curtorem chirurgia per insitionem, in a state-of-the-art, innovative specialization. published in 1597: “We restore, repair and make Neither do we want to resemble the stereotype whole those parts of the face which nature has that fiction portrays of us, nor imitate its frivol- given but which fortune has taken away, not so ity, trivializing the surgery we perform, its visible much that they may delight the eye but that they ostentation and luxury, or constantly appear on may buoy up the spirit and help the mind of the programs of frivolous scientific dissemination or afflicted”. in celebrity magazines. If not, we ourselves will If in any use of medicine one works with and ensure that we continue to be viewed as simple for the human body, in plastic, reconstructive and dream merchants, creators of beauty to clothe aesthetic surgery, the raw material is the human humanity. We will lose people’s respect for a body itself: to reconstruct it and give it beauty great specialization that perhaps we have not and functionality are the aims this specialization made known in its true dimension. We are still in

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time. Otherwise, let us not forget that even after −− McCarthy JG. Introduction to plastic surgery. In: Plastic his death, Tagliacozzi was condemned for inter- surgery, vol. 1. Philadelphia: W.B. Saunders; 1990. p. 1–68 fering with God’s creation, and his body was ex- −− Mosley L. Faces from the fire: the biography of Sir Archi- humed and re-buried in unconsecrated ground. bald McIndoe. London: Weidenfeld and Nicolson; 1962. −− Preamble of the Constitution of the World Health Orga- nization. New York, 22 July 1946. Official Records of the References World Health Organization, Nº 2; 100. −− Programa de la Especialidad de Cirugía Plástica y Re- −− Audoubert L. La gran travesía de los Pirineos. Barcelo- paradora, Secretaría de Estado de Universidades e In- na: Juventud; 1995. vestigación del Ministerio de Educación y Ciencia. Re- −− Canal Odisea. McIndoe: cirugía reconstructiva en la II solución 15-7-86. Updated in 1996. Guerra Mundial. −− Sociedad Española de Cirugía Plástica, Reparadora y −− Canal Historia. Archibald McIndoe and the Guinea Pig Estética (SECPRE). Available at: www.secpre.org Club. −− Tagliacozzi G. De curtorum chirurgia per insitionem. Ve- −− Coiffman F. Cirugía plástica, reconstructiva y estética. nice: Gaspare Bindoni; 1597. Bogotá: Amolca; 2008. −− Vilain R. Jeux de mains. Paris: Arthaud; 1992.

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Masters of Sex and Sexology

Helena Boadas

What might seem like an excuse for screening another controversial and polemic series with high-voltage sex appeal is actually one of the best reflections on scientific method to appear on the small screen. Based on the biography Thomas Maier wrote on William Masters and Virginia Johnson, the couple who convulsed the academic sphere in the nineteen-fifties and sixties with their studies on the human sexual response cycle, this series premiered in 2013 on cable network Showtime (Dexter, Homeland). It is an accurate and truthful retelling partially thanks to the chemistry between its leading actors, Michael Sheen and Lizzy Caplan.

“In 1956, a national renowned fertility specialist career, commits the indiscretion of becoming met a former nightclub singer. Ten years later, interested in human sexual response. Studies they published a scientific study, which revolu- in obstetrics in this period centered on the birth tionized our understanding of human sexuality.” of children, avoiding the process by which they Opening with these two sentences, this se- were conceived. He had patients who asked him ries set in the fifties −the first scene offers us a what they could do if they felt pain during coitus, gala dinner with fabulous fifties automobiles, fif- if they did not reach orgasm, or felt no pleasure. ties dresses and fifties music– has us ordering Frustrated because his best answer was to “take in a pizza to remain glued to the sofa for hours a lover”, “get used to it”, or “change your hus- on end. But Masters of Sex, furthermore, has band”, Doctor Masters realized there was a need an added value that makes it even more inter- to shed light on sexuality. The fact he had worked esting from my viewpoint: it is a real story. And with one of Kinsey’s disciples at the start of his one that is quite true to life. Because Masters’ career no doubt increased his interest in this field. and Johnson’s story was essentially the one the Kinsey had also revolutionized the history of sex- series tells. uality several years before Masters and Johnson. Readers may know of Kinsey’s studies, or have seen the film based on his life and work, entitled How did it all start? Kinsey, containing a lot of similarities to the series On one hand, we have Virginia Johnson, 32, Masters of Sex. It likewise conveys a clear idea of thrice-divorced, with two kids from her last mar- the developmental extent of the history of sexual- riage to a rocker, who had devoted her life to ity at the time. Yet for now let us return to Doctor singing until the year before. She is now working Masters, who is trying to begin studying human as a secretary at Washington University School of sexual response. Medicine, in Saint Louis, Missouri, filling in medi- Throughout medicine’s history, forbidden terri- cal insurance. She has studies in music and has tories have existed. It is as if humanity needed to begun studying sociology at the University. reserve part of the body for the realm of mystery, Meanwhile, Doctor William H. Masters, nearly the unknown, even the magical. Within this por- 40, an obstetrician at the same hospital, after tion, in this unpredictable space, we store every- more than ten years of an impeccable medical thing we do not know, or cannot properly explain.

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First it was the brain, then the heart. In the US in has the experience, the broadness of mind and the nineteen-fifties, it was the turn of sex. (Allow the frankness that Doctor Masters needs. Thus me a brief parenthesis: in an article on migraines by their collaboration begins −though Virginia has the neurologist Arturo Goicoechea, I recently read practically no university studies nor the slightest that this magical territory is once again the brain. knowledge of physiology– which will continue into Naturally, sex is not it, but the brain? Is it a magi- the 1990s, almost to the end of both their lives. cal territory? It seems so. It seems that it is help- What methodologies does the scientific study ful for us to be able to make statements such as use? In general, case studies, surveys, direct ob- “We only use 10% of our mental capacity”, or “We servation and the experimental method. So as Al- know practically nothing of the brain”, because we fred Kinsey used surveys, Masters and Johnson allow space for the unknown, the unexplainable use direct observation. And they do not have it and the unhoped for –in short, for magic. Close easy. Because observing the digestion process brackets.) We said that in the US of the time, this of somebody who has eaten an apple, for ex- forbidden territory was sex. It did not exist, and ample, is not the same as observing how this almost could not be mentioned. Doctor Masters same subject responds to sexual stimulation. In was obliged to work with prostitutes because he the series, we see how their study causes an up- had no other option. In the second scene of the roar in the university hospital. We all know that series, we see him shut in a cupboard spying on something interesting is going on in that office, a prostitute with a client, measuring the client’s but nobody knows exactly what. We even see sexual response, his timer in his hand. Working an attractive young doctor auscultating the wall with prostitutes caused many logistical problems, with his stethoscope. Here, in this difficult terri- aside from the fact that a sexual relationship be- tory, is where Doctor Masters and Virginia John- tween a prostitute and her client is not represen- son discover that their natures, their skills and tative of sexual relations in general. Furthermore, working methods complement each other so as most of them were affected by chronic pelvic to form a formidable team. All the aspects of Vir- congestion, a factor that also skewed the results. ginia’s character listed above are added to those Finally, after much insistence, the doctor manages of Masters: he is obsessive, demanding, rigor- to convince Willard Allen, his department boss at ous, meticulous, not greatly enamored of social Washington University, to include his study in the relations, of few words and very serious, though university. Allen warns him that it could be profes- one should not forget his subtle sense of humor. sional suicide, but the project goes ahead. These different natures of Masters and Johnson Doctor Masters needs an assistant and his are very well represented in the series, except, secretary does not fit the right profile. In the first in my opinion, in one respect. In the character of episode, we see her dressed in a green suit Doctor Masters that Michael Sheen plays, there conveying that hard-to-describe air –one having is a toughness that I am not sure the real person nothing to do with beauty– which certain women displayed. The strict and serious demeanor of a give off, as if they have begun to distance them- man of few words does not imply such sometimes selves from life, from pleasure. Doctor Masters’ unpleasant toughness, which I have not found in assistant must be a special woman. He knows any biography on William H. Masters. They rather that no female doctor would accept the position speak of his great humanity and warm capacity because it would compromise her reputation and for understanding. However, except for this facet, career. This is when Virginia appears in his of- both characters are well represented. fice as if by magic, deploying all her sensuality. They discuss the job position, their ex-husbands, Masters and Johnson’s importance and sex. “Before you leave, tell me, why would a in the history of sexology woman fake an orgasm?”. “To get a man to climax quickly. Usually so the woman can get back Was their work truly as relevant as the series de- to whatever it is she’d rather be doing.” Virginia picts? Yes, it was. Absolutely. Their studies re-

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vealed a clear before-and-after situation in the Now muscular tension, blood pressure, heart study of human sexuality. Furthermore, they laid rate and breathing accelerate more and more the foundations for the sexual revolution of the until orgasm is reached. Tension has reached its sixties. To start with, they managed to collect peak and is freed with this explosion. Involuntary highly accurate information on the physiological contractions occur of the man’s penis, the wom- changes in the human sexual response cycle. an’s vagina, and the anal sphincter in both. Men Moreover, they defined these phases: excite- ejaculate –although not always! It is not so comment, plateau, orgasm and resolution (Fig. 1). All mon, but orgasm may occur without ejaculation these data were key in order to profoundly un- in men. In women it is the opposite: normally vis- derstand the human sexual response cycle, es- ible ejaculation does not occur, though in some pecially to be able to treat possible dysfunctions. cases it does, composed of a mixture of urine Let us examine these phases in detail. and vaginal fluids. In the first, excitement, we observe an in- It seems that female ejaculation is currently crease in heart rate and temperature. Vasocon- in fashion in pornography, however, be warned: gestion of the pelvic area means that men ex- most female ejaculation in porn videos is false: perience an erection and in women, the vagina the actresses use tricks to simulate ejaculation. It expands and is lubricated. Breasts and nipples is important to know this because such fashions also become larger. can cause a great deal of sexual frustration in When the excitement reaches its peak, all the couples who think that certain practices or phe- changes are maintained at this highest level. This nomena are common, so they feel obligated to is the phase known as plateau, characterized by try and replicate them. In fact, yes, some women an intense feeling of pleasure. Though the per- experience ejaculation, but they are definitely not ception is one of calm, in this phase muscular the majority. Furthermore, these ejaculations are tension increases and this is when the sex flush substantially more modest than those we see occurs (some areas of the body, normally the on-screen. Many sexual problems arise from pre- chest and cheeks, redden). Secretion of vaginal conceptions or false ideas we have in our minds fluid increases in women and men tend to feel an about sexuality. So in Masters and Johnson’s intense urge to ejaculate. This phase’s duration is time, such false ideas generally arose from a lack highly variable. Some couples extend it to enjoy of information. Nowadays, we suffer from the op- this interval of pleasure for as long as they can posite: we have vast amounts of sexual informa- (moving very slowly, stopping for a few seconds, tion; the problems come from not understanding using gentler stimulation, or changing position, or digesting it well. Pornography is a source of etc.). In general, women have the capability to pleasure if used well: it can liven up our sex life extend this period for longer than men. with just a click. The danger is forming a mistaken idea of sexuality. This occurs often, because the models in pornography, though exciting to watch, are generally far from authentic sexuality. But let us return to the orgasm. As well as Orgasm the physical response, an emotional response Plateau also occurs. The bond between the couple increases through the release of certain hormones and through their union, which always signifies shared pleasure. This huge emotional release Excitement may be experienced as sobbing, crying out, or Resolution even laughter. Each of us expresses it in our own Start way. Both men and women can experience more than one orgasm in every sexual relation. The Figure 1. Diagram of the human sexual response cycle. male, if he has ejaculated, needs what is called

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a refractory period (a period of rest before get- was, without a doubt, their sex therapy. In fact, ting excited again). Women are fortunate in never most of today’s effective sex therapies were cre- requiring this; they can have one orgasm after ated through continuing Masters and Johnson’s another. After the orgasm (or orgasms), little by pioneering work. Their fundamental ideas remain little normal physical and psychological activity is 100% valid and their proposal continues to be ef- reestablished: this is the resolution phase. Vital fective, while being adapted to today’s needs and signs recover their equilibrium and a sensation of to new contributions and innovations. relaxation and general wellbeing takes over. It is important to clarify that sexual dysfunc- Masters and Johnson defined these four tions, the object of the therapy Masters and phases −excitement, plateau, orgasm and res- Johnson proposed, are just a small part of a olution– but, in fact, they omitted one, the first broad spectrum of possible problems related and essential phase: desire. Without desire, the to sex. The list would be extremely long. We sexual response cannot begin. Sexologist Hel- could mention: patterns of problematic behav- len Kaplan added it to the list in 1979, though, ior (exhibitionism, pedophilia, sexual aggression, in fact, Masters and Johnson had already spo- compulsive sexual behavior, risky behavior, etc.); ken of it. They specifically defend a concept of sexual identity problems; syndromes related to sexuality based on a couple’s relationship, a violence and victimization (due to sexual abuse in couple who communicate, far removed from the childhood, sexual harassment or sexual violence, purely mechanical exercise that sexual relations sexual phobias, etc.); syndromes related to repro- can sometimes become, a concept including deduction (due to sterility, unwanted pregnancies, sire. So, despite not including it in their list, it can abortions, etc.); and sexually transmitted in be inferred between the lines, especially in their fections, among many other problems and con- later studies. Despite all this, however, the merit ditions. Some of these disorders can be treated of having correctly included it in the phases of through therapy, though not all. One must always sexual excitement lies with Kaplan. seek a suitable professional for each case, and In men, excitement generally occurs faster, but often an interdisciplinary approach is required. the duration of the plateau is shorter and more- Leaving aside this spectrum of diverse prob- over drops sharply. In women, excitement occurs lems related to sex, I want to focus on the aim more gradually and is maintained for longer, but of Masters and Johnson’s therapy: sexual dys- they also have the capacity to extend the plateau functions. We speak of sexual dysfunction when and their orgasms. Furthermore, their descent is difficulty exists during any phase of an individual’s gradual (Fig. 1). sexual response (desire, excitement, plateau, or- All these data were significant to fully under- gasm or resolution) and this sexual response sig- stand the human sexual response cycle and, nificantly deteriorates. This is a weak definition, above all, to treat possible dysfunctions. I say but to date we do not have a better one. “above all” because Masters and Johnson’s most Classic sexology distinguishes between male important contribution to the history of sexology and female sexual dysfunctions (Table 1). Al-

Table 1. Sexual dysfunctions.

Women Men

General sexual dysfunction (frigidity) Erectile dysfunction (impotence)

Vaginismus Premature ejaculation

Orgasmic dysfunction Delayed ejaculation

Ejaculatory incompetence

Ejaculation without orgasm

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though this classification is already outdated, it to the lack of a bodily response at the moment of continues to be used, and therefore is useful to excitement (problems of tumescence), with the know. So traditionally, women experience three orgasm, or else with pain during sexual relations. sexual dysfunctions: general sexual dysfunction It is useful to note that the incapacity to achieve refers to a lack of desire or excitement, and to the or maintain an erection and the absence of vagi- incapability of feeling pleasure; vaginismus is an nal lubrication have exactly the same origin. Each involuntary contraction of the vagina that makes expression of a dysfunction has its peculiarities in penetration impossible; orgasmic dysfunction is each sex and each person, of course, but it is im- the inability to have orgasms. Where men are portant to understand that common origin. Only concerned, five dysfunctions are described: vaginismus is an exclusively female dysfunction, erectile dysfunction is an incapability or difficulty in its own category. of maintaining an erection; premature ejacula- It goes without saying that where sexual tion is an early ejaculation, shortly after beginning health ends and dysfunctions begin is highly sub- penetration, while delayed ejaculation is the op- jective. At what point does a man, a woman, or a posite phenomenon; lastly, there are men who couple decide that his orgasm occurs too soon? can have an orgasm but cannot ejaculate (ejacu- It may be that a specific time for one couple signi- latory incompetence) and the opposite, men who fies a problem, but not for another. At what point can ejaculate but not experience an orgasm. does her orgasm occur too late? The answer is At first sight, sexual dysfunction in men and in the same. One couple will seek solutions and will women seem very different, but in fact this is not adapt; while another will experience it as a prob- so. Modern sexual research proposes a fresh, lem that affects their sex life. Often there is a clear much more accurate classification of dysfunc- problem, such as vaginismus, or the lack of an tions. We now understand that, since sexual re- erection stopping penetration, but things are not sponse in men and women is practically identical, always so obvious. Sex can be enjoyed even so are their dysfunctions (Table 2). without an erection. In sexology, we understand Current sexology, then, explains that, though that each couple is a world unto themselves and expressed differently, sexual dysfunctions in men we are simply here to help people enjoy their sex- and women are the same. They may be related uality. Above all, nobody should suffer as a result

Table 2.

· Disorders of sexual desire: alike in both sexes. · Problems of tumescence: − In women: these occur as a lack of vaginal lubrication. − In men: these occur as a lack of penile erection. · Problems of orgasm: − Depending on the time of appearance: Shortly after commencing coitus: In women this is not considered a problem. In men it is considered a dysfunction if it is too early in his, her or both of their opinions. A long time after commencing coitus: In men this is not considered a problem. In women it is considered a dysfunction if it is too late in his, her or both of their opinions. − Absence of orgasm: alike in both sexes. · Disorders of sexual pain: alike in both sexes. · Vaginismus: a disorder exclusive to women.

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of their sex life. Often consultations are solved by eliminate the habit of masturbation. In the early an hour’s conversation in which some false belief twentieth century, Wilhelm Reich defended onan- is discarded. Sometimes it is that easy. ism to help recover natural sexual function. It also Until Masters and Johnson, sexual problems seems quite shocking that, following Galenus’s were classified as medicine or psychiatry. In other recommendations, some of his psychoanalytical words; problems were classed as purely physio colleagues in Vienna masturbated their female logical or as mental health disorders. Attempts patients in therapy sessions. This type of therapy were made to resolve the former with medical is currently prohibited by codes of ethics. What treatments, and the latter basically through psy- all of these examples point to is that often, what choanalysis, without very effective results. What doctors or therapists call natural is, in fact, a val- Masters and Johnson did was to give sexual diffi- ue concealed by a supposed scientific truth. It culties a human and especially a relational dimen- is very difficult −perhaps impossible– to establish sion. They understood that a sexual problem was what constitutes “natural sexuality” according to a problem of the couple, not just one person. scientific criteria, and almost always ideological, And that is how they treated it: the therapeutic moral or cultural criteria come into play. object was the couple’s relationship. To give an One sensational example of the connections example: until that time, if a man had problems between science and morality is the following. achieving an erection, physical causes were It occurred in 1973 and was the greatest suc- sought within medicine; or else he was treated cess in medicine, almost a miracle: millions of by psychoanalysis to discover the origin of his people were cured at a stroke, one afternoon. impotence. After Masters and Johnson, such How? They simply chose to delete homosexual- erectile dysfunction was considered a problem ity from the Diagnostic and Statistical Manual of within the couple’s relationship: perhaps the man Mental Disorders (DSM), which describes mental felt pressured, was scared of failure, or of losing disorders. Its editions are updated every several his partner. Or any other reason within the rela- years, and although it has been highly criticized tionship sphere might be considered (naturally, because it medicalizes behaviors that perhaps once having eliminated any medical problems). should not be medicalized, such as homosexual- This change of approach signified a revolution in ity in its time, it is the manual that psychiatrists treating sexual dysfunction. and psychologists currently use. Nowadays, ho- The fact that their therapy contained no trace mosexuality is no longer a perversion, but it was. of dogmatism or arrogance was a key factor in its Who can assure us that what we currently think effectiveness. Because sex therapy has a pitfall: of as perversions (or paraphilias, as former per- what is normal, natural or healthy sexuality? Who versions are called) will not be included among establishes this? Is it possible for scientific criteria natural sexual behaviors in a few years? It will to be combined with cultural ones? Is it possible depend on a combination of the science, culture that the therapist unknowingly functions accord- and morality of the period. In fact, this is simply ing to his or her morality? a conflict between the individual and society. The Let us take the example of masturbation sex therapist uses training, information and com- throughout history. In ancient Rome, the re- mon sense to find the exact point, the best equi- nowned Greek doctor, Aelius Galenus, recom- librium possible. mended that therapists masturbate their fe- Masters and Johnson developed a sex ther- male patients to recover their health. Yet in the apy that strives to put aside moral prejudices to eighteenth century, the Swiss doctor Samuel view the couple exactly as they are and under- Tissot, though brilliant in other areas, was con- stand each sexual problem within their circum- vinced that masturbation caused very serious ill- stances, with huge amounts of common sense. nesses. In the nineteenth century, many women Yet although Masters and Johnson managed underwent an ablation of the clitoris (as well as to take sexual dysfunctions out of the context in Europe and in America until very recently) to of medicine and psychiatry, it is clear they did

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not arrive there by themselves. Several research- able manner of explaining sexuality and counter- ers prior to them began to lay down the bases ing myths and taboos. of what would become modern sexology. Pos- sibly the most important of them was Alfred C. “In order to function sexually, a person Kinsey, the first researcher to speak of sexual needs only a reasonable state of general habits in scientific terms. This was an almost good health and an interesting and revolutionary act. He conducted questionnaires interested partner.” with thousands of men and women, each containing hundreds of questions. The interviewers As mentioned, Masters and Johnson’s work be- were very well selected, even knowing the ques- gan to lay the foundations for the sexual revolu- tions by heart, and the questionnaires were well tion. It goes without saying that the sexual revo- designed, so that the research was thoroughly lution meant huge freedom for men and women valid. His results brought to light habits that (above all the latter). One could speak of equality supposedly did not exist. For example, sexual of the sexes, the appearance of the contraceptive encounters outside marriage were found to be pill and, in many countries, free abortion. With the frequent, masturbation was quite common and sexual revolution, different types of sexuality were many people had had occasional homosexual normalized, including extramarital relations, chil- experiences. One of Kinsey’s successes was to dren born out of wedlock, homosexual or single- create a scale for classifying one’s degree of het- parent families, and even same-sex marriage. All erosexuality versus homosexuality. This fact was this was extremely necessary and was fabulous. revolutionary, because until that time the popu- However, there is a large “but”. The sexual rev- lation were classed as homosexual or hetero- olution stems from the freedom to have sexual sexual. However, Kinsey’s research showed that relationships with whomever we want, and that this division is not possible: sexual orientation is is good, but we have reached a point that was a continuum that stretches from pure heterosex unforeseen in the original sexual liberation: the uality to pure homosexuality. Each and every one of us is situated at some point on this continuum. The Kinsey Scale (Fig. 2) is still used in some questionnaires on sexuality, and all the information in his surveys, published in two volumes, is Heterosexuality very valuable. After Masters and Johnson, and above all from the sexual revolution onward, sexuality became normalized and studies have become Homosexuality common (Durex Sex Survey, Encuesta de salud y hábitos sexuales from the Spanish National 01 2 3456 Institute of Statistics, studies by the Spanish Kinsey Scale Federation of Sexology Societies, etc.). Perhaps 0: Exclusively heterosexual the last study that constituted a social change 1: Predominantly heterosexual, was Shere Hite’s, published in the sixties, which only incidentally homosexual 2: Predominantly heterosexual, builds on Masters and Johnson’s and Kinsey’s but more than incidentally homosexual studies. Hite conducted thousands of question- 3: Equally heterosexual and homosexual naires on attitudes and sexual behaviors in men 4: Predominantly homosexual, and women. The Hite Report was criticized for a but more than incidentally heterosexual 5: Predominantly homosexual, lack of statistical and data processing accuracy. only incidentally heterosexual In fact, this is true, because more than an analy- 6: Exclusively homosexual sis it is a compendium of stories. Yet it is likewise hugely important, because it is an extremely valu- Figure 2. Kinsey Scale.

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trivialization of sexual relations. Sex is an act reasonable state of general good health and an of deep and intimate communication that has interesting and interested partner”. physical and emotional consequences. Remov- ing such importance from sex and turning it into What happened to Masters and Johnson? a mere act of physical release is causing −para- doxically– the same problems that stem from be- At the time of writing this chapter, two seasons ing forced to have sexual relations in a marriage of Masters of Sex have been screened while a we do not want to be part of. third is in production. Nevertheless, since we Masters and Johnson, in their later works, know Masters’ and Johnson’s real lives, I can spoke of that intimate connection, of the pro- tell you that (spoiler alert!) he finally got divorced found dialog between two bodies that transcends from Libby, with whom he had three children. mere physical contact. They themselves experi- Doctor Masters and Virginia Johnson were mar- enced such a communion with each other. And ried in 1971. The clinic which they had opened they chose each other, even while Doctor Masters in Saint Louis a year earlier became the Masters was still married. One reading is that the quest for and Johnson Institute in 1978. They worked to- a sexuality that goes beyond a physical release gether until 1992. Virginia, at 60 years old, keen can be interpreted as a conservative, outdated, to enjoy her final years, her family life and to trav- almost puritanical stance. I believe it is the oppo- el, became weary of a husband who spent al- site: it now seems to be the more revolutionary most his entire day locked in his office working. act. Sexual liberation has provided the very free- In 1993, they divorced. A year later, William, ill dom to do what we want. Now we must choose with Parkinson’s, retired and remarried, this time well. This does not necessarily mean choosing a to an old flame from his childhood. The Masters partner to get married. We can choose to have and Johnson Institute closed its doors in 1994, sexual relations with someone of the same sex, though Virginia kept working almost right up to with two people, or simply not have them with her death. anybody. Why not? We can do what we wish. But Doctor William H. Masters died in 2001, and it must have some purpose and, above all, make Virginia Johnson in 2013. us feel good. Nowadays, we see many women in the consulting room who believed in this half- baked sexual revolution along Sex and the City Bibliography published lines, who do not choose their sexual partners by the researchers cited well because they never learned to discriminate −− Human Sexual Response. Masters and Johnson, 1966. in that sense. The result (naturally, avoiding moral −− Human Sexual Inadequacy. Masters and Johnson, judgment of any kind) is that they feel bad. People 1970. −− The Pleasure Bond. Masters and Johnson, 1974. are capable of experiencing vast sexual pleasure if −− Sexual Behavior in the Human Male. Alfred Kinsey, the partner we are with (in whatever form, wheth- 1948. er a marriage, friendship, de-facto, or casual sex −− Sexual Behavior in the Human Female. Alfred Kinsey, partner) acknowledges us. If they recognize us. If 1953. we like them and they like us. −− The Hite Report on Female Sexuality. Shere Hite, 1976. −− The Hite Report on Men and Male Sexuality. Shere Hite, Doctor Masters, at the end of his life, said: “In 1981. order to function sexually, a person needs only a −− The New Sex Therapy. Helen Kaplan, 1974.

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CSI and Forensic Medicine

Adriana Farré, Marta Torrens, Josep-Eladi Baños and Magí Farré

A successful model for TV franchising, this CBS series about a state-of-the-science forensics team who can solve even the most complex cases in a matter of minutes has opened franchises in three different cities, as well as a new division on IT crime called Cyber. The original fiction, which went to air in 2000 starring the now legendary Gil Grissom as Head of the Las Vegas CSI Unit, shut up shop in 2015 after 15 straight seasons and a total of 337 episodes. Its Miami and New York spin-offs, first screened with notable success in 2002 and 2004 respectively, wound up ten years later. Cyber, which is still on air at the time of writing, every week attracts an average of ten million viewers.

Crime Scene Investigation (better known as CSI work of a team of forensic scientists and crimi- or CSI: Las Vegas) is a US TV series created by nologists who belong to the city’s police depart- Anthony E. Zuiker and produced by Jerry Bruck- ment and investigate some of the crimes occur- heimer, which premiered in October 2000 on ring there. The team is trained to solve each case the CBS network, winding up after 15 seasons, through the gathering and analysis of evidence in 2015. The last episode was feature-length, at the scene of the crime, seeking the guilty and screened in the US on 27 September 2015. interrogating witnesses and suspects. They work CSI was a television success in the opening de- around the clock until they resolve the situation. cade of this century, with a worldwide audience Each episode has a main plot related to a violent of over 73.8 million viewers in 2009. In 2012, it crime and a subplot that affects the investigators. was recognized as the most-viewed TV series in The crime or felony is almost always solved in a the world for the fifth year running, since CSI has single episode. been screened in over 200 countries. Even so, in the Emmy Awards it only reaped three trophies The keys to success in technical categories. It premiered in Spain in of the forensic scientists 2002 and its early seasons were hugely successful, gaining average audience shares above According to the experts, the original series and 25%. It ran free-to-view on Telecinco and Cuatro, its franchises owe their success to blending among other channels. crime fiction and medical or scientific genres, as Such success allowed it to become a fran- well as their style of filming. In terms of the for- chise that spawned three offspring: CSI: Miami mer, the highlight is on the preciseness and de- (2002–2012), CSI: NY (2004–2013) and CSI: Cy- tail in the gathering and analysis of the evidence, ber (on air since 2014). The structure of all three taking the perspective of a forensic autopsy, the CSI series set in cities is very much alike: investi- use of fast, sophisticated technology to conduct gate the scene of the crime live, gather evidence analyses, including genetics and toxicology, and and solve the mystery, though each uses differ- the investigators’ scientific knowledge. ent characters. The original series is set in the US In its day, CSI used an innovative method of city of Las Vegas (Nevada) and centers on the filming, using many special effects, plus original

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use of color and light. Furthermore, it is filmed on ing, analysis of biological or material remains, 35-mm cameras, typically used in cinema mov- ballistics, insect recognition, DNA analysis and ies. The storylines tend to happen at night, the detection of poisons and medication. All this de- cutting is frenetic, the action changes quickly be- velops at a frenetic pace and the results obtained tween interiors and exteriors while the aesthetic almost immediately. The investigators consult the in certain scenes resembles a video clip. The forensic pathologist and discuss the autopsy re- initial hypothesis of the facts and their resolution sults in detail. They scour databases to identify are presented as a flashback, either in black and the case, the suspects involved or others who white or sepia. may be related to the case in some way. The Due to its popularity, it has received several work progresses with further questioning and the criticisms both for its degree of graphic violence analysis of new evidence, some from subsequent and sexual content as well as for the rather unre- murders or fresh crimes related to the case. More alistic image of the procedure for solving a crime. clues are revealed, or where there is a new clue, It has been accused of being thoroughly exces- a fresh analysis is made. The suspects may be sive in its violence. It does not shy from clearly questioned again, new evidence is found or the showing the injuries victims suffer (always with old reviewed, and the final (correct) hypothesis is plenty of blood), nor does it avoid decomposing formulated. The case is solved by unveiling and flesh riddled with revealing insects. During the grilling the perpetrator. necropsy, cadavers are clearly shown with their entrails on view. They carry out simulations of CSI in opposition to reality blows, reconstructions of the identity of the guilty, and each meticulous detail in the lab analysis of Despite the fact the show’s producers consider the evidence is always shown. One of the most it realistic, CSI is nothing more than fiction. There original aspects of the series since it began is the are vast differences between the on-screen story use of enlargements and micro-cameras to show and the reality of police and forensic investigation. wounds in the greatest detail, reveal a bullet’s tra- To start with, on CSI it seems like all the team jectory, or explore injuries or the inside of organs. members are able to take part in all phases of the investigation. They travel to the crime scene, process the scene, gather evidence, interrogate Applying the CSI method witnesses or suspects, analyze evidence and al- The scripts of CSI and its franchises are highly most always operate in the streets or in build- similar. It starts with the presentation of the crime ings to arrest the criminal. It is unusual in that or felony before the opening credits. Then the CSI they are armed and use their guns if the situation investigators arrive to make a highly detailed visu- so requires. In the final instance, they solve the al inspection of the corpse and the crime scene. crime. They all seem to be experts, though it is They review the victim in detail, photograph the true that some of the technicians only work in the scene and carefully gather the evidence. This lab, some police do not do biological work and task is shown with great thoroughness. At this the forensic pathologist only conducts autopsies. point, witnesses and possible perpetrators are The reality of criminal investigation and foren- also interrogated while the first arrests are made, sic medicine in every country is quite different. In if deemed necessary. The investigators discuss fact, there is a clear separation between judicial the murder details and form their early (normally police, who investigate and arrest the accused, mistaken) hypotheses regarding events, either scientific police, who gather and analyze evi- at that moment or after the initial analysis of evidence, and forensic scientists, who work in insti- dence. tutes for legal medicine. Each concentrates on The work continues in the forensics lab, where their own specialization, without trespassing into they analyze the evidence using technologically any other professional areas. In Spain, the foren- advanced methods. These include finger-print- sic analyst does not form part of the investigative

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Medicine in Television Series

team. He or she is a technician who only states Naturally this contrasts with reality, with restric- her or his findings before the judge. The most tions on equipment, staff and techniques, even in surprising aspect is the role of the CSI characters countries such as the US. Many techniques can- in questioning and in arrests –clearly an exag- not be applied, and in others, the results may be geration, more in the realm of fiction than truth. delayed for months or even years. Science re- The characters in the CSI team appear to be quires patience: it is tiresome and takes time. The scientists, or at any rate, police officers who apply means are all too often insufficient for the need. scientific methods to solve cases. They use sci- Fiction forces cases to be flashy and complex, ence, logic and deduction instead of firearms. Evi- to stimulate interest and last the length of each dence is the most important factor, and it is always episode’s storyline. In the early seasons, several conclusive, in contrast to the interrogations. This cases were often investigated simultaneously in is obvious in their attitude: the people interrogated a single episode, but recent seasons have about lie whereas the evidence is absolute. At the crime one case per episode. The crimes are often scene, they dress characteristically, identified by based on real cases, but they are presented more their team jackets. At the police station and crime realistically or are clearly exotic. An analysis of the lab, they wear lab coats and are surrounded by first season revealed a total of 74 cases investi- analysis apparatuses and computers. The labora- gated in 23 episodes. Most corresponded to vio- tory is dark and crowded with equipment, flasks, lent crime (72%), especially murders (64%), rob- precipitate beakers, test tubes containing myste- beries, rapes, suicides, kidnappings, blackmail rious liquids and high-technology microscopes. and accidents. Most of the detainees were male The actors are seen handling samples, transfer- (77%) and white (87%). The victims were mainly ring liquids with pipettes and placing vials into an male (66%) and Caucasian (91%). The crime analyzer. They review the results and reach perti- was committed mainly using firearms (36%) and nent conclusions. They all seem to have the skills knives or other cutting instruments (17%). In fact, of lab researchers and use scientific and medical most investigations are routine and it is uncom- jargon with ease. The reality is quite different, as mon for a police officer to frequently investigate the arguments given above show. such spectacular or complex cases. Both the gathering of evidence and samples, The series reinforces the perception that as well as their processing and laboratory analysis criminals always leave sufficient clues to enable a are done using very advanced technology. A suit- crime to be solved, which occurs in most cases. able apparatus for determining a result is never Despite continuous advances in forensic science, lacking, the equipment is all ultra-modern and situations exist where there is simply insufficient –even more significantly and startlingly– the results evidence to solve the case, or the proof available arrive lightning fast. This situation is valid whether does not help solve it. It seems that officials re- consulting identity databases, processing and sponsible for ensuring the law is obeyed and fo- detecting fingerprints, or analyzing toxicology rensic analysts are always one step ahead of the or genetic DNA evidence. It seems as if the en- criminals, which often is clearly not true. tire staff and technology are at the service of the case in hand. There are no delays, breakdowns, The CSI effect queues or waiting around. Everything comes out at the first try with no need for a repeat. The epi- One of the greatest problems the series brought sodes do not show the time or preparatory proce- to light were the high expectations created dures that analysis requires, or the time required among people in real life. Watching the series, to extract samples, which is always much slower. one would believe that crimes can be solved in Everything is very easy: the sample is placed in two hours, data processed in minutes and that the suitable apparatus and the required result im- forensic laboratories are crammed with high-tech mediately obtained. In the series, all the crimes equipment fitted with lasers to do all the work for are solved within hours or a few days. you. The truth is that processes are long and te-

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dious, though that does not make them any less ing it to exaggerate situations so as to entertain important. and consolidate its audience. If, furthermore, one The CSI effect, sometimes called “CSI syn- learns something, even better. Reality tends to drome”, refers to the various ways that the ex- be more routine, slower and more boring, though aggerated representation of forensic science in as the saying goes, “sometimes, truth is stranger CSI and other TV programs influences public per- than fiction”. ception of criminology. The advanced techniques shown in these series heighten expectations of References judges, juries and criminals on trial, regarding the evidence found at a crime scene. The term −− Deustch SK, Cavender G. CSI and forensic real- is employed in the US for the demand by juries ism. Journal of Criminal Justice and Popular Culture. 2008;15:34-53. for more forensic evidence in criminal trials so as −− Durnal EW. Crime scene investigation (as seen on TV). to make sounder decisions. The same phenom- Forensic Science International. 2010;199:1-5. enon is applied to defense lawyers, who request −− García Borras F. La serie CSI como metáfora de algu- a greater amount of incriminating evidence. And nas facetas del trabajo científico. Revista Eureka sobre the same happens with the police: demand for Enseñanza y Divulgación de las Ciencias. 2005;2:374- proof has likewise increased. The truth is that in 87. −− Houck MM. CSI: reality. Scientific American. 2006;July: most cases, this simply overloads crime and fo- 85-9. rensic medicine labs with work. −− Hughes T, Magers M. The perceived impact of Crime The success of CSI and other similar series Scene Investigation shows on the Administration of increased viewers’ interest in forensic medicine Justice. Journal of Criminal Justice and Popular Culture. and the number of enrollments in courses on 2007;14:259-76. the subject. In Spain, reliable data does not ex- −− Kopacki C. Examining the CSI effect and the influence of forensic crime television on future jurors. 2013. VCU ist of its influence on enrollment in the Degree Theses and Dissertations. Paper 3178. in Criminology many universities offer. However, −− Machado H. Prisoners’ views of CSI’s portrayal of foren- as occurs with all popular series, it is likely that sic identification technologies: a grounded assessment. it stimulates interest in the subject and so more New Genetics and Society. 2012;31:271-84. people choose it as a vocation. Nevertheless, the −− Marrinan C, Parker S. La guía definitiva. CSI: Crime confusion between criminology and forensic sci- Scene Investigation. Barcelona: Ediciones B; 2008. −− Oros M. La nueva ciencia forense en la novela y en el ence can lead to the frustration of expectations cine actual. InterseXiones. 2011;2:199-218. from those starting to study the former without −− Smith SM, Stinson V, Patry MW. Fact or fiction? The knowing what, in fact, it is. myth and reality of the CSI effect. Court Review: The One of the negative effects of CSI and simi- Journal of the American Judges Association. 2011. Pa- lar series is that criminals can learn from them per 355. and, as a result, better prepare their actions and −− Tous A. Paleotelevisión, neotelevisión y metatelevisión en las series dramáticas estadounidenses. Comunicar, Re- carry them out in more detail to leave as little in- vista Científica de Educomunicación. 2009;XVII:175-83. criminating proof as possible at the crime scene. −− Tous A. El sorgiment d’un nou imaginari a la ficció The result is greater difficulty for investigators at- televisiva de qualitat. Quaderns del CAC. 2008-09;31- tempting to solve cases. 32:115-23. In the end, it is more important to be able to −− Tous A. El text audiovisual: anàlisi des d’una perspectiva mediològica. Doctoral Thesis. Universitat Autònoma de distinguish between reality and fiction, between Barcelona; 2008. what is a police investigation and forensic medi- −− Wikipedia, the free encyclopedia. Crime scene investi- cine, compared to what is TV fiction. The latter gation (CSI). Available at: http://en.wikipedia.org/wiki/ aims to depict reality in an amusing way, lead- CSI:_Crime_Scene_Investigation

-96- Notebooks of the Esteve Foundation Nº 42

Homeland and the Emotional Sphere

Liana Vehil and Luis Lalucat

The producers of the action-packed 24, Howard Gordon and Alex Gansa, have at last earned critical praise on this adaptation of the Israeli series Hatufim, first broadcast on the cable network Showtime in 2011 and still on air. What began as a game of suspense and ambiguity between a CIA agent suffering from bipolar disorder (Claire Danes) and a US marine recently freed from captivity at Al-Qaeda’s hands (Damian Lewis), has developed into a fascinating spy fiction. Year after year it is ranked among the favor- ites at the Emmy Awards (it harvested six trophies in its premier year), and has even “hooked” President Obama himself.

Its different emotional states, as well as its an- sions taken at lightning speed, it represents the guish, have generated a great deal of interest supremacy of action over introspection. Though among the different narrative arts. The history of the series’ main aim does not lie in describing its literature lets us see into the lives and passions characters’ mental functioning, the scriptwriters of fascinating characters. We could mention offer viewers elements to identify with them by Madame Bovary’s day-dreaming and emotional showing how continued exposure to situations of deception in Gustave Flaubert’s masterpiece, or risk can affect one’s mind and emotional states. the affective sufferings of the characters in Fy- The storyline focuses particularly on the main odor Dostoyevsky’s novels, held captive by their character, Carrie Mathison, a CIA agent who has emotional development and a heightened intro- been diagnosed with bipolar disorder. spective view of their life experiences. Film in par- Bipolar disorder is considered one of the ticular has explored the human personality and most significant psycho-pathological disorders helped us to experience the reactions of fictional affecting mood. This name is given to disorders characters as our own. Firstly films, and more that are characterized by mood swings. One’s recently TV series, have fascinated us with the mood consists of a range of emotions that differ- lives of their everyday heroes, showing us their ent experiences evoke in one. These emotional likenesses and revealing our own fears and de- states and resulting behaviors are considered sires. The treatment given the emotional states healthy and within the norm when they adapt to constitutes, in fact, the cohesive core of any film the context in which they are expressed. Gener- genre such as melodrama, which from Douglas ally, at the risk of oversimplifying for clarification’s Sirk to Pedro Almodóvar, and including Rainer W. sake, within the range of reactions appropriate to Fassbinder and recently David O. Russell’s Silver their setting we would include annoyance at an Linings Playbook, submerges us in the depths of injustice, sadness when facing loss, or happiness the most extreme human emotions. at good news. Losing control in expressing one’s Homeland is an action series that centers on feelings would also be considered acceptable as the coverage of international conflicts and the would exaggerated annoyance at highly stressful fight against terrorism. Fast-paced, with deci- situations if they occurred momentarily. On the

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contrary, in assessing a disorder one should con- lucinations. Sometimes they require psychiatric sider whether these reactions occur repeatedly hospitalization. or in an exaggerated way, with no apparent quali- In the above descriptions, it is easy to recog- tative or quantitative link to outside stimuli, and nize some of the moments and behaviors Carrie whether they determine the individual’s relation- experiences: she seems to fall into a hypomanic ship with surrounding reality. state when she makes decisions following her im- Considered to be a serious mental disorder, pulses without considering the risks associated bipolar disorder, formerly called manic depres- with them, or shows signs of an exaggerated sion, is characterized by changing moods. These self-esteem that does not seem congruent with swing between two opposite poles: the mania, or her context. Yet at the same time, she maintains phase in which the subject appears exalted, eu- a high level of competence. She is capable of phoric and harbors grandiose delusions on one establishing a significant personal relationship hand; and on the other, depression, the phase to which she remains emotionally faithful, and where sadness, inhibition and thoughts of death of modulating her irritability. Nevertheless, she predominate. Such fluctuations can be observed also displays a more serious clinical presenta- in Carrie’s character when at times she gets into tion at such times as those behaviors escape situations of great risk from solely following her her control, she loses her capacity for empathy, impulses, disregarding her colleagues’ warnings, becomes submerged in her emotions and even or else the opposite when, discouraged, she has distorted perceptions and invents delirious shuts herself away, and is wracked by sobbing, conspiracy ideas. This is when she needs to be even attempting suicide. hospitalized. This initial schema of cyclical alternation be- Carrie likewise shows symptoms typical of the tween mania and depression does not occur depressive phases when overwhelming feelings evenly in all individuals suffering from this dis- of sadness and despair, tiredness, anxiety and a order. Cases occur in which the alternation be- marked alteration in her vital rhythms, such as in- tween euphoric and depressive states are com- somnia and appetite loss, appear. bined with more or less prolonged phases of full The information provided by the series might stability and functional restitution, with a good also bring to mind a mixed episode; in other response to treatment, absence of associated words, one simultaneously combining manic and problems and a return to a fully independent life. depressive symptoms. So symptoms of hyperac- Even so, most people tend to face more of a tivity, worry, feeling down, a tendency to cry and torpid evolution, with frequent relapses and the feelings of guilt can be associated. As the series manifestation of other associated clinical features reflects, such variability of the mixed episode like anxiety, substance abuse and some degree hugely complicates diagnosis and treatment, and of functional deterioration. has the more negative consequence of increas- During manic phases, patients can also mani- ing the risk of suicide. fest contrasting states. On one hand is hypo- Given the variability of clinical presentations, mania, a euphoric state in which individuals ap- bipolar disorder has been subdivided into two pear to be in a buoyant and expansive mood, conditions: bipolar I disorder (BP-I), is character- alongside irritability and impulsiveness, disquiet, ized by alternation between depressive and man- agitation, uninhibitedness and verbosity, which ic episodes; and bipolar II disorder (BP-II), by de- nevertheless does not significantly interfere with pressive and hypomanic symptoms. In our case, daily activities. On the other hand is a marked Carrie’s behavior rather resembles BP-II disorder. state of mania in which manic symptoms of a Investigations developed around the etiologi- more invalidating nature predominate. The latter cal hypotheses of the disorder show the impor- seriously interferes with the individual’s functional tance of the genetic load, which points to greater performance, going as far in certain cases as de- personal vulnerability and seems to confirm that veloping psychotic symptoms like delirium or hal- the presence of a disorder on the bipolar spec-

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Medicine in Television Series

trum in a parent increases the chance that de- may involve an evolution toward chronicity. In scendants will suffer from it. As occurs with other fact, the frequency of critical episodes gradually complex mental states, the causes tend to be increases, until two episodes occur in a very brief due to multiple factors and consequently the in- interval of time. fluence of other aspects linked to development The quality of therapy plays a large role in the are highlighted. Altered or unstructured family disorder’s development. Because it is a highly relationships in childhood may be another fac- complex disorder, it requires a complete treat- tor added to the genetic variable, and contrib- ment, both medical and psychological, incor- ute to forming a fragile psychological apparatus, porating rehabilitative interventions. The series capable of unleashing the disorder in later life. In fundamentally covers pharmacological treat- addition to having a father suffering the same ill- ment, the situations requiring psychiatric hospi- ness, some of Carrie’s family experiences could talization, and certain general recommendations be related to the tricky regulation of her moods. in relation to healthy living patterns. Given the Her mother’s difficulties in confronting mental suf- importance of the subject, we will briefly outline fering, plus her own instability in relationships and a description of the recommendations issued in her father’s manifest psychopathology, bring to clinical practice guides. mind an atmosphere in which emotional conflicts When designing therapeutic interventions, generate circular dysfunctional movements that great significance is attached to the extent of ca- feed into each other, causing huge discomfort pability and commitment the individual must as- and hindering the resolution of vital problems. Es- sume. Any professional intervention runs the risk cape from the suffering as a mitigating resource, of not being suitable, or being interrupted, with- instead of dealing with grief, may have scarred out the involvement and agreement of the suffer- her family’s emotional environment. In the series, er. So it is essential that the individual is aware of Carrie rarely trusts in introspection to confront the distinctive features of their disorder, that they and overcome her conflicts and losses, while she know the protective and risk factors associated opts for life choices that may encourage the de- with it, as well as the importance of maintaining a stabilizing of her emotions and contribute to her high level of “self-care”. For the same reason, it is psychopathological development, such as her advisable that individuals are able to establish alli- taste for risk and a choice of job that often sub- ances with the professionals responsible for their jects her to situations of stress and high risk to treatment and with different family members. her physical and mental health. Despite her scarce awareness of the risk, Car- We know that bipolar disorder often evolves rie always trusts somebody: when she refuses toward chronicity. Its most invalidating manifesta- to talk to a psychiatrist who might monitor her tions tend to appear progressively over a lifetime, medication, she tends to follow the advice of her and, in general, limit the individual’s functional sister, who is both a family member and doctor. In capacity. However, it is not shown like this in the critical circumstances, she places herself volun- series, since Carrie’s behavior seems perfectly tarily in the hands of the mental health system to adapted to her employment context. She of- receive electroshock therapy. Unfortunately, from fers the image of somebody frequently dealing what we can see, she is not consistent enough in with emotional crises and physical risk yet she caring for herself, one of the significant aspects of achieves optimum results in resolving the tasks maintaining clinical stability. she is set. Only at certain moments does the Currently, pharmacological treatment is con- tension get too much, affecting her capability to sidered fundamental, above all based on lithium work and the caliber of her interpersonal rela- salts and other mood stabilizers, but so is partici- tions. We do not have sufficient data to evaluate pating in a therapy process of psychological and the foreseeable evolution of the disorder, and one rehabilitative interventions. Carrie’s father, who must always consider the variability of personal suffers from the same disorder, tells his daughter characteristics. However, in Carrie’s case, this about his personal experience with the medica-

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tion he is on. At other times, he tells us about the an important figure in the US for many years, and prescription of different drugs, though he men- is acquiring increasingly greater prominence in tions no medical monitoring system. Spain. It does not appear he has been recom- Although the capacity for resilience and recov- mended or tried any structured psychological ery the individual displays should always be taken or psychosocial intervention beyond certain into account, bipolar disorder poses significant general recommendations on healthy living pat- problems of a diagnostic and therapeutic nature. terns. In contrast, currently, a better prognostic In effect, among the various episodes, appar- is associated to systematic health monitoring ently symptom-free, deceptive intervals tend to that offers information on the illness and train- appear, which may lead to the sudden abandon- ing in strategies for combating it. This aims to ment of treatment and the appearance of fresh optimize handling of the disorder, instructing in relapses. This is what occurs on the occasions early detection and consequent immediate ac- when Carrie abandons her drug treatment be- tion when new symptoms appear that forewarn cause she does not feel the need to keep tak- of a relapse. ing them. This behavior, highly inadvisable in care Electroshock therapy, which the heroine un- practice, seems to be linked to the most critical dergoes, is recommended in cases of serious periods of her life and leads to greater psycho- depressive symptomatology in which any other logical instability. therapeutic intervention has been shown to be As stated in the Guía de práctica clínica del unsuccessful, or if the situation is deemed a risk trastorno bipolar (Practical Clinical Guide to Bipo- to life. Carrie’s desperation and her sense of lar Disorder) published by the Spanish Ministry of finding herself at a dead-end attract her to this Health, according to several studies conducted in option, despite being informed of the negative different sociocultural media, patients with bipolar consequences such treatment can have on her disorder display symptoms during a substantial cognitive capacities. part of their lives. These phases with clinical mani- In the course of treatment, great importance festations can cover from a third to half of their is attached to the presence and participation of lives, with predominance of depressive symp- family members and other close friends who can toms. It is therefore essential to treat this disorder contextualize symptoms and grant them a mean- longitudinally, knowing that after the appearance ing that resonates with individual identity. They and resolution of manic or hypomanic symptoms, can encourage the maintenance of healthy be- the risk exists of a fresh relapse. Between two haviors, the reduction of risky behaviors and help thirds and three quarters of patients hospitalized accommodate phases of greater stability. Such for mania will again be admitted for the same participation can also be an element of training to cause in the future. The percentage of patients suitably intervene in crises, after prior agreement with a single episode does not surpass 15%, with the affected individual. Homeland grants a while the most frequent percentage of relapses privileged role to family. The sister is idealized over a lifetime falls within the 7–22% range. as a mother figure and absent carer, while she The seriousness linked to bipolar disorder is also acts as guarantor that the pharmacological generally attributed to lifestyle factors associated treatment is being followed. She is attentive to with it, and to substance abuse, which frequently the phases of instability that can precede a crisis, occurs during or between episodes. and offers support during the times Carrie is inca- Based on these data, Carrie’s future does pable of fulfilling responsibilities taken on impul- not seem very optimistic, though it is true that sively. The father personifies a figure who speaks in her case some of the more frequent conse- from a viewpoint of first-hand knowledge and quences of the disorder are not present, such as experience, aware of the disorder’s seriousness functional deterioration and difficulty in maintain- and having overcome his most conflictive peri- ing satisfactory employment activity. Were such ods. His is the survivor’s voice, which has been evolution confirmed, it would enable us to trust

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Medicine in Television Series

in a satisfactory evolution. However, as we see in The series chooses to convey a message of Homeland, Carrie does not maintain her pharma- hope, one that is not always fully justified, but cological treatment regularly, she consumes al- which hints at the chance to overcome the disor- cohol often, experiences continual risk situations der. Nowadays we know that certain well-known and her vital rhythms match the most inadvisable figures who are no longer with us suffered from behaviors for reaching affective stability. In the se- this disorder in their time. We admire them for ries she remains constantly active, is efficient at their historical value and courage in a sustained her job and recovers from her most critical mo- fight to recover their faculties. Currently, moments ments by adapting to new contexts with resolu- of hope are also experienced every time a well- tion. In part, this capacity to overcome is related known and respected person makes their disor- to her character, a true fictional heroine who is der known and agrees to share both their suffer- capable of becoming larger than life itself. Yet it ing and their triumphs with us. is also true that there are people who can face The scriptwriters display a firm sense of bal- dramatic situations thanks to their great personal ance and sensitivity by presenting a heroine who fortitude. We should not forget that studies moni- suffers from a mental disorder that is considered toring people with this disorder record a (small) serious, without hiding the more disquieting as- percentage of cases that evolve favorably. pects of her illness. Yet meanwhile they get us to In Homeland, description of bipolar disorder value and identify with her due to her overall per- symptoms in their different evolutionary moments, sonality. Carrie is a competent person, who pos- of the fluctuation between phases, of pharmaco- sesses myriad personal capabilities. She is suc- logical and medical treatment in general, of the cessful and respected in her professional sphere. recommendations concerning lifestyle habits and She is surrounded by people who love her and the importance of family participation in the heal- worry about her, and her identity is linked to her ing process, respond faithfully to descriptions of overall personality, not to her illness. This is now international clinical classifications and the rec- the challenge set by the movement fighting to rid ommendations in the clinical practice guides in those people suffering from a mental disorder –and use. As we saw, it is possible to find examples by extension their family members and the profes- of many aspects of the disorder presented with sionals attending them– of any sort of stigma or great coherence. The series also conveys to what discrimination. Carrie prompts no rejection from extent this disorder can affect different aspects viewers. Instead, it is easy to identify with her, feel of life, guiding us on the combative attitude that jealous of her successes and share her suffering. suffers must maintain. The series lacks a greater reference to the It is likewise true that some of the most in- need for integral, structured, integrated and on- validating and painful consequences of this dis- going therapy, which responds to the extreme order are omitted or smoothed over, as shown complexity of a disorder that affects different in clinical practice. Many affected individuals see aspects of life. On one hand, this means mental their lives completely changed and do not man- health, and with it the capacity to tolerate emo- age to overcome the progressive worsening of tional pain, create conflicts and be able to build their personal relationships or their progressive satisfactory personal relationships, and on the loss of functional autonomy. Behind the appar- other, physical health in its different dimensions. ent dynamism and speed of response that Carrie Nevertheless, Homeland’s great truth, from the displays could nevertheless hover her difficulty in viewpoint of disseminating information on mental regulating her moods or her incapacity to resolve illness, consists of coherently integrating, with- her emotional conflicts, incorporating prepara- out interfering in the plot action, a positive and tion processes and coping with the suffering they seductive character who suffers from a serious lead to. mental illness without judging her.

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Notebooks of the Esteve Foundation Nº 42

Olive Kitteridge and Depression

Oriol Estrada Rangil

HBO miniseries tend to have few rivals in the award ceremonies. There were good reasons why this exquisite, four-episode production, aired in 2014, triumphed at the Emmys, winning a total of eight statu- ettes. Three of them went to the cast, responsible in good measure for its impeccable results. Bill Murray, Richard Jenkins, and especially Frances McDormand, all help to reflect the personality of a dour woman with depressive symptoms in an objectively bucolic setting. The script adapts the novel of the same name written by Elizabeth Strout, the 2009 Pulitzer Prize winner.

It seems as if the entire world knows what depres- discussion on how different North-American gen- sion is, but very few people truly understand it. erations have confronted this illness. It is not unusual at all to hear somebody say In the original novel, Olive Kitteridge is basical- they are depressed. It means no more than ly the common nexus by which the stories of sev- that they are rather sad for some setback or mis- eral families in that small town of Maine are told, hap. Even if in some cases such sadness may be where neighbors still know each other by first and more than justified, in others it is no more than last names. She is not necessarily the protago- the simple expression of a passing sentiment, a nist, which is an aspect the TV series has man- feeling that will vanish once the worrying problem aged to respect up to a certain point. Olive does has been solved, or even if the sun comes out the not take absolute prominence until we reach the next day. Depression has entered our everyday last of the four episodes forming the miniseries. vocabulary, but that does not mean we are using This leaves the door open for us to get to know the word correctly. What is more, in the immense the stories of the people surrounding her, and we majority of cases we are doing a disservice to realize that depression and mental problems in people truly suffering from clinical depression. general abound in the chilly lands of Maine. When Olive Kitteridge explains to her son One of the first characters introduced is her Christopher what depression is, she describes husband, Henry, ironically the village pharmacist. the sufferer as somebody with “bad wiring”, His first customer is Rachel, who apparently suf- someone poorly put together. This is merely a fers from depression, and she tries to convince figure of speech, far removed from depression’s Henry to give her more Valium than he should. complex reality, but behind it lurks an idea that is The pharmacist’s reaction is a good example of actually based on many psychobiological theo- how people who truly do not understand depres- ries regarding this mental illness. The award- sion react to it. First, he advises her to get out of winning HBO miniseries, Olive Kitteridge, which the house, since according to him it is “good to adapts Elizabeth Strout’s Pulitzer-winning novel, get out when you’re feeling blue”. Henry uses the perhaps does not aim to place depression cen- word “blue”, which can mean both “depressed” ter-stage, but thanks to tiny gems such as the and “sad”. His customer replies: “Christ, Henry, aforesaid scene, it is a good departure point for a blue is what I feel on the good days”. The phar-

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macist continues in the same vein, recommend- interest in certain activities), weight loss or in- ing insistently that she goes to buy light bulbs of crease, insomnia or hypersomnia, psychomotor a higher wattage, at least until the end of winter slowdown or agitation, asthenia (the sensation of when the days get lighter and less gloomy. This physical weakness), recurring feelings of useless- scene perfectly sums up the way many people ness or guilt, a reduction in intellectual capacity keep treating and (mis-)understanding this dis- and recurring thoughts of death or suicidal ideas. order. And this customer expresses what many All of this must affect the individual’s social or people suffering from clinical depression would working life in some way, and must not be related scream to the four winds every time somebody to organic diseases or drug use, nor with habitual tried to jog them out of this state with a couple of grieving for somebody who is deceased. well-meaning platitudes, not understanding that So is Olive Kitteridge suffering from depres- the problem needs more than brighter light bulbs sion? She is convinced she is. And it is likely that and a few strolls around town. the DSM mostly agrees with her. Her irritability Clinical depression is not simply being down- is something that leaps out –she has very little cast or sad. Neither does it refer to feelings that patience and is capable of getting annoyed over one might experience over a work or relation- any detail. Anhedonia is one of the characteristics ship crisis, or even at the death of a loved one. that best defines Olive’s personality, and through- Problems like these can unleash depression, but out the series she shows a (pathological?) lack despite most people having phases like these in of interest in any of the things that happen to their life, not everybody ends up suffering from her. Henry gives her a card for Valentine’s Day, this disorder. Clinical depression is a syndrome, a which ends up in the waste. Years later, he gives set of symptoms related to the individual’s affec- her another card, simply to say he loves her, and tive capacity. One in six people will suffer from it she gives him a hug, displaying possibly the least at least once in life, most of them from 18 to 44 emotion ever seen on TV. Her son’s wedding is a years old, on average starting at 27. Women are good example. On a day in which her husband at greater risk of suffering from it, doubling the gets emotional and feels happy because his son prevalence ratio of men. Its origin is from multiple will be living nearby, Olive is incapable of show- factors, or rather that different elements intervene ing anybody a smile, even telling her son that she which cause the illness; one of these tends not hopes the ceremony will be short. to be enough, but these factors must occur to- Clearly, all of this affects her capacity to re- gether. late socially, and many guests feel chastised by It is not easy to diagnose. It cannot be de- her conversations. Yet physically it does not ap- termined by analyzing blood or any other kind of pear that Olive has many problems, since she is biological markers to indicate whether somebody always busy, whether cooking, tending the gar- is suffering from depression. A psychopathologi- den or working at the high school. However, the cal, clinical diagnosis must be made, normally only scene in which we see her teaching shows based on the directives set in the Diagnostic and us how strict she is in the detention room with Statistical Manual of Mental Disorders (DSM), students’ punishments (to give us yet another published by the American Psychiatric Associa- example of her impossible nature). Even so, we tion. This manual describes a number of symp- still do not know whether Olive suffers from other toms which, according to their presence and symptoms that would be required to diagnose degree, determine whether a person is suffering her with MDD. The question is, do we not see from any type of depression. So to diagnose a them because they are not shown, or because major depressive disorder, the individual must they do not exist? display a minimum of five of the symptoms de- A better example seems to be the pharmacy scribed, for at least two weeks. These symptoms customer, Rachel, who is incapable of enjoying include sadness, dysphoria and irritability, anhe- anything, who spends her day sleeping on the donia (which is the incapacity to enjoy or display sofa (hypersomnia), forgets to collect her son

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from school (affecting her family life) and needs mainly due to genetic reasons, or because he Olive to come and spur her on to get dinner ready has led his entire life watching his mother act like for her boy. It is that incapacity to see the posi- a depressive person? Living on a daily basis with tive side of things, and having the certainty that somebody who considers that everything is done nothing can improve in future, which best de- badly, who barely smiles and makes your life hell, scribes the typical patient of depression. And it as Christopher recognizes years later, is not the is not something that will change with a slap on best way of preventing depression from develop- the back and a 200-watt light bulb. As presented ing. Remember that not everything is based on at the start, Rachel seems to be the most ste- genes. Many other factors must come into play reotypical example, though we then see that in to unleash a depression, and the social factor is reality her problem is even more complex. likewise important. What probably is not so well known is the ge- Health sciences have other resources for try- netic factor, which can play a significant role in ing to overcome this obstacle: adoption studies the development of clinical depression. Doubt- and studies on twins. Adoption studies try to de- less, ignorance of this factor helps stoke certain termine to what extent genetics have influence opinions and ideas on how depression functions. in a specific environment. So a comparison is But Olive, ahead of her time, is clear that a ge- made between children adopted by a healthy netic relationship exists. Resuming the conversa- family and high-risk children, those who live with tion on depression with her thirteen-year-old son, their biological parents and suffer from the syn- she insists that he must know what it is, since his drome. What has been observed is that children family has always suffered from it. She is con- with the genetic factor who have been adopted vinced that her son will also suffer from depres- by a healthy family have greater chances of de- sion throughout his life, and the truth is, as an veloping the illness than the general population. adult he will end up taking Prozac and attend- But once more, controlling the environmental facing different types of therapy. During dinner, Olive tor can place this in doubt, so studies of twins mentions her father, who suffered from depres- seem the best way of determining the respective sion and ended up committing suicide. Further- weight of genetics and environment. In these, the more, she claims that her husband’s mother went results in different types of twins are compared: through the same. To this, her husband replies monozygotic (who are identical) and dizygotic that his mother simply “had her moods”. Wheth- (who share only half each other’s genes), and er Olive is right, or simply analyzing their parents one of the conclusions is that genetic inheritance and son from her own bias of considering herself plays a considerable role (present in 40% to 60% depressive, is something that viewers must de- of cases). This tends to occur more frequently cide by watching the series to the end. But at that with serious depressions and mainly in the case point, they table the issue of genetics, the heredi- of women, but it also occurs in men, especially in tary factor of depression, which is something the those cases in which depression starts at under series should be applauded for. 30 years old. Science seems to agree with Olive, and Studies on twins also enable environmental studies of families show that an individual has a factors to be identified that can have some effect greater risk of suffering from depression if a di- on the development of depression. This is an ill- rect family member has suffered or is suffering ness triggered by multiple factors, and the genet- from it. While the prevalence in the general popu- ic or environmental questions alone do not seem lation is about 5.4%, this increases to 15% for to be enough of a trigger. These studies show family members with precedents (figures that are, that certain stressful life events have a causal ef- in fact, a far cry from Olive’s grim determinism). fect. Some examples are the death of a loved Nevertheless, this type of study has a risk, which one, separation and even harassment (such as is that the environmental factor cannot be con- bullying). This means that among identical twins, trolled. Does Olive’s son suffer from depression despite them both having the same genetic risk,

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if one experiences certain stressful episodes dur- question, which could explain why so many peo- ing their life and the other does not, the former ple with a depressive disorder are concentrated has a greater probability of suffering from depres- in the same spot. The typical endogamy of more sion than the latter. Yet we must emphasize the isolated regions may offer an explanation for this idea of non-determinism: the fact that one has (apart from the author’s choice to set the story a genetic predisposition, and even experiences there, naturally). Yet as noted, this is a continual several stressful events during their life, does not sum of factors, and one must not only take into mean they will definitely develop depression. Per- account psychosocial and environmental as- haps the clearest example (a somewhat simplistic pects, but genetic ones. view, we admit) is that of a lottery: almost every- Olive seems to display some characteristics body has tickets, and some people have many typical of a depressed patient, yet throughout more than others, but that does not guarantee the series, she is able to overturn our assump- they will win the lottery. So Olive has given her tions with some of her statements and behaviors. son several tickets, but it is impossible to know Perhaps her posture regarding the illness is what whether the winning ticket is among them. locates her more in the terrain of fiction than in re- What the series makes clear is that being born ality. She claims she suffers from depression, but and living in Maine guarantees you have a good this does not seem to constitute a problem –it is number of tickets in that lottery. Is this because rather a feature of her personality. One could say of the climate? The idea that a cold, dark location that she even feels happy with it, and has never such as the state of Maine, with a lot of humidity done absolutely anything to shake off this apathy, and not much sun, is the perfect place to de- or to improve her social relationships. The irony velop depression is a widespread literary cliché with her husband being the pharmacist is that –and we see little sun in the series. The popular she has never undergone pharmacological treat- belief that one’s surroundings, in the most literal ment. Furthermore, it seems she has no great sense of the word, have an effect on one’s mood love of psychologists and psychiatrists either, is made patent here. But is this belief true? It since, in her son’s words, she thinks “headshrink- seems to be true that winter or fall, the seasons ers are the devil”. with least sunlight, have an effect on our sero- No, Olive does not seem to be upset at having tonin levels (the so-called mood or pleasure hor- to live with depression. She goes even further: mone), and so are periods that are more prone when talking about the illness with her son, she to depression. Seen in this light, it seems that says it goes with being smart, that only “normal” Henry was partially right when he recommended people are happy and only intelligent people suf- Rachel purchase more powerful light bulbs. In fer from depression. Ernest Hemingway thought this argument, cold places such as Maine have the same, saying it was quite strange to see a propensity for developing the illness. Therefore, somebody both intelligent and happy. The idea the number of individuals with depression would that mental illness is associated with intelligence tend to be greater in comparison with other ar- or creativity has existed for a while. It even seems eas with a more agreeable climate. However, in to have been demonstrated that certain types of a study conducted in the US from 2006 to 2008, psychiatric disorders (schizophrenia, bipolar dis- the prevalence of different forms of depression order) are more prevalent in artistic profiles. But was greater in states such as California and Flor- the idea that intelligence and depression have ida, which enjoy a much warmer climate. In fact, a more or less direct relationship is something it is precisely in the southern states (Louisiana, that has never yet been fully proven. Some stud- Arkansas, Mississippi, Alabama, etc.) where the ies claim this is so, while others deny it. Some prevalence of depression is much greater, far sur- claim that intelligent people tend to worry more passing 10%, while in Maine it remains at 7.9%. as they are more aware of the dangers in their So if the environment is not always a determi- surroundings, and it is precisely this attitude that nant, we have to fall back again on the genetic enables greater survival. Nevertheless, if we re-

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call that US study on depression, we see that Olive avoids, of a character whose mother com- not having higher studies seems to have a rela- mitted suicide. Likewise, the suspicion hovers tionship with the prevalence of depression: the that certain accidents, one fatal and the other not lower the educational level, the more chance of so, were in fact intended. There is even a con- developing it. So concluding that depression is versation in the third episode where the issue of exclusive to intelligent people is still too risky and suicide is openly raised as a solution to all one’s simplistic. Firstly, because the concept of “intel- problems. ligence” remains, to this day, a highly contro- The reality is that, of all those who at some versial subject. The idea that there are different point express a wish to kill themselves, only types of intelligence –therefore that we cannot 10% are successful. In the US around 30,000 speak of intelligent people but of people with cer- people commit suicide every year, but more than tain intelligences– is gaining increasing relevance. 500,000 attempt it. There can be several failed at- For example, if we speak of emotional intelligence tempts, and a third of them will try again within a (a relatively novel concept), research shows that, year. It is the fourth cause of death in the US, and the greater one’s emotional intelligence, the lower most victims are from 15 to 24 years old. Speak- the incidence of depression. Meanwhile, another ing of depression, one in six people who suffer study demonstrated that people with greater lin- from depression try to commit suicide (implying guistic intelligence were more prone to suffer from they are unsuccessful). In the light of these data, anxiety or even depression. the degree of effectiveness of the characters in The latter quickly prompts us to think of Olive Olive Kitteridge is surprising. As mentioned, in the Kitteridge again, more specifically her lover, the lit- same series they often talk about suicide. Some erature professor, who she considers interesting, see it as a solution, even an honorable way of and truly intelligent, and with whom she seems to ending their misery and problems. Olive seems to get on much better than with her husband. The play with the idea quite disconcertingly. She will same occurs between Olive and Rachel’s son defend at some point that suicide is no solution at (Rachel, the depressive customer we saw early all to one’s problems, or add that it is a dirty way on) with whom she deals more tactfully than with to go, and always affects somebody negatively, her own son. Likewise, this young man seems while at other later times in her life, she claims to understand his literature professor extremely that once her dog is dead, she will have nothing well, closing this circle of intelligent depressives left to do than shoot herself. She says this in an with affinities in the town of Crosby. Shortly after- exaggeratedly rational tone, arguing that she no wards, we discover both he and his mother suffer longer has any more roles and so, therefore, her from bipolar disorder, not depression, reinforcing existence has no more meaning for anybody. afresh the relationship between intelligence and Like depression itself, suicide is a complex, mental illness, and meanwhile the genetic ques- multi-factored phenomenon. Purely psycho tion of its development. Are we being sold a ro- logical and social factors may intervene, but it mantic idea of depression? I would not go so far, is also explained by neuro-biological processes. because Olive’s story is anything but romantic. Though much remains to be studied on this is- She will tell her husband he is too good for her, sue, it seems clear that suicide victims have a low and apologize for being a bad wife, recognizing concentration of serotonin, the substance that, that she has made his life really tough. And she as mentioned above, modulates our feelings of herself, when talking about her father’s suicide, pleasure and moods. In the brain, this mainly says it is neither a pretty end nor a clean one. seems to affect the neurotransmission of sero- Inevitably, suicide always hovers around de- tonin in the prefrontal cortex, the hippocampus, pression. In the first scene of the series, we see a the hypothalamus and the septal nuclei. Among very aged Olive heading out into the woods with its functions, the prefrontal cortex is in charge of a loaded gun, ready to end her life. The death cognitional control and behavior, which, if dam- of her father is ever-present, as is another, which aged, can increase impulsiveness and affect our

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capacity for decision-making. If to this is added even suffer mixed episodes. These episodes damage in the hippocampus, which controls can last between one and two weeks, and occur emotions and stress, and the capacity to recall throughout the day. Rachel, who seems to be the recent facts, then we have an individual who can classic depressive patient, later reveals she has lose their capacity to make suitable decisions for bipolar disorder. In fact, this is a common diag- the context in which they find themselves. Lastly, nostic error, since many patients only seek help damage to the septal nuclei seems to be related during their depressive episodes. to development of pessimistic feelings. There- Bipolar disorder may sometimes be accom- fore, committing suicide is not normally a rational panied by certain psychotic symptoms (including and premeditated decision, but a cumulus of fac- hallucinations), and is often diagnosed wrongly tors added to each other until they explode. This as schizophrenia. As a matter of fact, one of the is why Olive Kitteridge’s calmness when planning most surreal and striking images in the series is her own suicide is possibly quite divorced from linked to this disorder. At the start of the second the reality of a depressive person. episode, we meet the adult version of Rachel’s It is not just depression that is closely linked son, Kevin Coulson, who has returned to the to suicide, but also bipolar disorder (likewise town hiding a weapon in his car trunk. Olive, who seen in the series), schizophrenia, post-traumatic seems to have a sixth sense concerning mat- stress disorder, borderline personality disorder, ters linked to suicide, ends up getting into the consumption of alcohol and drugs, and certain car to distract him. This is when we realize Kevin stressful facts that may be related to financial may have inherited the illness from his mother. problems or interpersonal relationships. It could Although the only thing we know is that thanks be one or several of these factors together that to this, he has studied psychiatry, probably to end up leading a person towards attempting understand what happened with his mother and to take their life. Yet depression remains one of what is happening to him. We realize our error the foremost reasons. It is thought that between here, of having thought that she too was another 45% and 70% of those who attempt or commit depressive in Crosby’s catalog. Kevin’s childhood suicide suffer from depression. Even so, it is still memories help us understand that more was go- only specific profiles among those suffering from ing on there. depression who attempt it, profiles with violent Olive Kitteridge is, for many reasons, a great and impulsive characteristics. It appears con- series, with memorable characters and acting, clusive that many suicides go through a period especially Frances McDormand as Olive. Though of great anxiety right at the time of making the she herself, as the series producer, has recog- attempt. Once more, this does not seem to be nized that at no time did they aim to place depres- Olive’s case. In the opening scene, she is head- sion center stage, it is undeniable that the series ing towards the woods and making all her prepa- invites reflection and even debate on this mental rations with a certain lack of urgency, as if she illness (along with others), and how it has been were preparing a picnic rather than a suicide. portrayed over the decades. Within Olive’s family, We have mentioned bipolar disorder several starting with her father, continuing with her and times. Since it appears in the series, and be- ending with her son, viewers are offered three dif- cause of its relationship to depression, it is worth ferent ways of dealing with depression. We have examining to some extent. Bipolar disorder is that absent father, who at 45 years old commit- characterized by a series of extreme changes in ted suicide, but who hailed from a generation in mood. During certain episodes, some characters which depression was probably not understood. feel very happy, extremely happy (a phase known It was definitely not considered an illness, and as a manic episode). However, shortly afterwards the only way out he found was to shoot himself they get down and go through a depressive epi- in the kitchen. Then we have Olive, much more sode, with all the features we have described aware that depression is an illness, and further- here for depression. In some cases, they can more hereditary. For her, the only thing to do is

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go forward and endure. We could even say that ing with them has changed a great deal, not she rebels against the illness and does not allow just based on medical advances but also about it to take her over, but her means of bearing it what society thinks of these disorders. Perhaps seems to be cruel and antisocial. Lastly, Chris- medicine nowadays is much more advanced topher represents the “modern” way of facing it. concerning knowledge of depression from most This is the generation of Prozac, psychologists of society, and this series helps us reconsider and psychiatrists, and even of therapy groups. many aspects regarding it, starting with the ge- Through these three generations, we have seen netics question. a social evolution of mental illness, from not even But is Olive Kitteridge somebody who truly mentioning it to spending the day talking about suffers from depression or not? The definitive your problems with others, as Olive Kitteridge answer can be found in the final scene of the se- would surely say her son does. ries, and that scene returns us once more to the It is important always to bear in mind the start of this chapter, and to rethinking whether context in which mental illnesses are presented, the use we make of the word “depression” is since history has shown that the form of deal- correct or not.

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Notebooks of the Esteve Foundation Nº 42

True Detective and the Attraction of Evil

Luis Lalucat and Liana Vehil

This thriller in the form of an anthology is a clear example of the rise and fall that TV fiction can undergo from its first to its second season. Created and written by Nic Pizzolatto, the eight episodes in the first season, which went to air on HBO in summer 2014, submerge viewers in a sordid and disquieting investigation being carried out by two antagonistic police officers on a serial murder case. Yet the show drew fans not by the police officers’ investigations, but because of the deep discussions Matthew McConaughey’s and Woody Harrelson’s characters got into. The change of storyline, cast and location it underwent in its second season did no favors to what had been one of the revelation series of the year.

A pair of detectives in Louisiana’s Criminal Inves- Robert Mitchum, the serial killer of Seven (David tigation Division, Marty Hart and Rust Cohle, are Fincher, 1995) or the later Zodiac by the same assigned a crime in 1995 that bears markedly director (2007), No Country for Old Men (Joel strange features typical of a ritual murder. In the and Ethan Cohen, 2007) or the perverse criminal course of the investigation, as events are revealed, dwelling within Hannibal Lecter in The Silence of we see not only their reactions to the crime, but the Lambs (Jonathan Demme, 1991). Although also how the powerful emotional shocks accom- all of these offer some common features, they panying these crimes affect their lives. This emo- also display marked differences in their behavior. tional buffeting is exchanged in the context of the The figure of the monster goes back to investiga- complex relationship between the pair. tions carried out on serial killers and ritual crimes, Years later, in 2012, a new case given to two covering both the characteristics of the criminals other detectives reopens the investigation. Marty and their victims, as well as their modus ope- and Rust, who have left the Criminal Investigation randi. Division, are interrogated separately about the In True Detective, the monster is a serial killer events of 1995. This shows the repercussions who is described to us as having the qualities of those events had on their lives. The situation a sadistic and perverse psychopath, or as some- prompts both men to open a new investigation one with an antisocial and sadistic personality on the fringes of the official one, leading to identi- disorder. In this sense, this person meets most fication of the perpetrator, confrontation with him of the behavioral characteristics of serial killers. and to the case being solved. The killer’s criminal profile includes premeditated The entire history of film is rich in figures de- behaviors, the use of deceit, a precise choice of picting horrific behavior, personified by characters victims, a progression in criminal action (kidnap- who display psychopathic behaviors, project- ping, torture, mutilation, death) and disposal of ing evil onto their surroundings. Such characters the body with a return to his habitual activities. populate a gallery of portraits covering extremely The monster of the series is skillful in his crimi- diverse makeups, from the psychopath of subtle nal actions, at the same time as he appears to yet malevolent manners in The Night of the Hunter engage in normal behavior in his occupation, (Charles Laughton, 1955), masterfully acted by which keeps him in touch with the child popu-

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lation among whom he selects his victims. His by serial killers, and even go as far as estimating crimes are planned, always choosing the most there are 150 to 300 serial killers in that coun- vulnerable victim. And he does so in a broad yet try. So they constitute a significant social and identifiable radius of action, in which he carries criminological phenomenon, even if their clinical out his actions of capture, torture and death. In classification remains under debate, despite a such actions, he furthermore leaves a recogniz- definition of the clinical symptoms having been able trace through unnecessary elements or fea- arrived at within the sample of criminal psycho- tures in the carrying out of the crime. However, paths as far back as the 1940s. Obviously, this these traces accompany the crime, constituting is a controversial question, since inclusion or not elements that, in one way or another, enable within psychiatric classification of psychopathies the same perpetrator to be identified: the tying, and personality disorders also concerns the legal wounds and torture inflicted on his victims, the imputability of the criminal acts and behaviors of arrangement of the bodies for discovery, and the such subjects. presence of strange objects around them. Equally controversial is identification of the In fact, throughout the season, we only know etiopathogenesis of such disorders, in which it this character through the result of his crimes, is difficult to define to what extent the biological, the plot’s unifying thread. The ritual crime that psychological and social components intervene launches the investigation leads to discovering in the genesis and maintenance of such crimi- a long chain of murders and disappearances of nal psychopathic behaviors. While participation children and young people that has been occur- of a psychogenic component based on child- ring over time, all seeming to point to the same hood experiences of situations of physical and author. Nevertheless, the storyline also gradually sexual maltreatment and abuse is generally ad- reveals the direct or indirect participation of other mitted, the absence or distortion of such social agents. Only at the end of the series is the mon- and affective bonds also appears to be relevant, ster revealed as a flesh-and-blood person, char- related to acquisition of the necessary emotional acterized in his living situation by an atmosphere maturity, capacity for relationships and construc- of degradation and incestuous relationships. The tive exchanges, as well as the incorporation of sole reference to explanatory or etiological ele- social values. The line the monster uttered above ments in his behavior is expressed in a line he seems to refer to a vengeful attitude, in response himself pronounces: “You know what they did to to humiliations, maltreatment or harassment suf- me? Hmm? What I will do to all the sons and fered in his childhood. daughters of man”. The other side of the coin is represented by Serial killers have long held a morbid fascina- the victims, children and young people who tion for viewers, and still do. This is partly linked to have been kidnapped, tortured and killed. The showing the relationship between an external ap- series shows us just one case that did not lead pearance of normality in everyday behaviors and to the victim’s death, since they manage to criminal actions that reveal an absolute disregard rescue the victim at an advanced stage of the for victims. It is likewise to do with showing highly process. Immediate and long-term serious psy- elaborate criminal procedures, in which sadism chological consequences are shown as the vic- and pathological sexuality appear together and tim’s incapacity to develop psychologically and are shown openly in public. This is especially so, emotionally. Years later she lives shut away in a as in the case of True Detective, when the victims psychiatric institution, and displays the mental are children and young people. functioning of disconnection characteristic of au- This type of behavior has been investigated tism. This framing of the character speaks of for years, both from the police and forensic ex- the serious consequences that may foreseeably aminer’s perspective as from the psychiatric stem from an extreme, prolonged traumatic ex- viewpoint. American studies state that 1% of perience on the still-forming mind of a child or homicides committed in the US are performed adolescent. For all the above reasons, the figure

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Medicine in Television Series

of the serial killer, such as we have analyzed here, in the information he provides us regarding his becomes configured in the collective imagining life story and reactions to different significant life as the representation of evil. events. It is relevant to consider an initial block Productions that depict the figure of the psy- of events and their evolution since childhood. He chopath, the serial killer and the monster tend to is the son of an affair of his mother’s with a sol- present viewers with characters or antagonists dier on leave. She abandoned both the father on who constitute a counterpoint, in the shape of his return and her two-year-old son. Father and common personalities, who in contact with the son move to Alaska, where they live in an isolated lead characters reveal new aspects of them- situation, until Cohle decides to return to Texas. selves. In this interaction between these two There, he marries and has a daughter, experi- contrasting characterizations, not only the pro- encing family life for the first time. The accidental tagonists’ lives but their minds are affected. This death of his daughter ends his marriage in a de- likewise occurs in True Detective, so we will try to structive emotional context for the couple. Once include it in the analysis we conduct. more he experiences abandonment through his It is commonly accepted that exposure to wife leaving. His daughter’s death, both the fact traumatic events generates psychological con- itself and its consequences on family and himself, sequences in the exposed subjects, and clini- seems to become a determining event in his later cal history offers numerous examples of such evolution. A job transfer from the Larceny division situations. People who have been exposed to a to Narcotics begins his descent into hell. Living traumatic event, whether experiencing it them- undercover for four years among drug traffickers, selves, witnessing it, or recognizing its conse- he begins abusive substance use, takes part in quences, receive a psychological impact. This violent acts, causes several deaths and reaches is still greater when deaths or threats to physical a borderline situation, causing him to be admit- wellbeing have occurred. Each person responds ted to a psychiatric hospital. The diagnosis re- to the event in a different way, according to their mains unclear, since he says that “for a long time own psychological makeup, but a certain de- after, I... I didn’t really sleep. Nightmares, PTSD, gree of fear will habitually have been generated, exhausted nerves, whatever”. The description of a hopeless response, or they will have experi- his state prior to admission is compatible with enced intense horror. The psychological conse- the clinical symptoms known as post-traumatic quences possess a certain specificity, linked to stress disorder (PTSD), understood as a set of their memory, making themselves felt in dreams, individual reactions to exposure to intense stress or in maintaining a persistent psychological –and factors. This presupposes a one-off or ongo- sometimes intense– unease with everything re- ing, intense, emotional reaction to one or several lated to the traumatic event. Some symptomatic such factors, for a brief or prolonged period. The manifestations of such consequences are shown point of departure may be situated in the death in physiological alterations that can affect not only of his daughter and later family decomposition, sleep and appetite, but habits and behaviors. when presumably a process of identity was being True Detective shows how contact with a initiated at the family’s core, creating the corre- crime of special characteristics acts as a trau- sponding affective bonds, a sense of responsibil- matic event that affects the investigators in ity and participation in a shared project. This loss charge of investigating it. Below, we will analyze does not lead to full grieving, and the couple’s in what way the series presents the psychological consequent rupture prompts him to act in an ever characteristics and certain psychopathological more precipitate and self-destructive fashion, re- elements of the main characters, Cohle and Hart. peatedly putting his own life at risk. Cohle is described in the series through his Once he is released from hospital, he refuses behavior and comments about himself, and the an offer of retirement on “a psych pension” and opinions of others interacting with him. Yet it is asks to be transferred to the homicide division. necessary to store all these descriptive elements So he chooses to rejoin the police force, to once

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more form part of a group, playing on the duality The resolution of the case, in a fresh collab- of identity and belonging. In his new job, the case oration with Hart, seems to open up a new life he and Hart are assigned activates the charac- perspective for him, as if he had finally managed, ter’s main conflicting cores afresh, centering on for the moment, to break the infernal cycle his life the loss of his daughter, and giving him a need to had become. get to the heart of the matter, to solve the case The series presents PTSD in a manner similar so as to face his own conflicts. The successive to habitual diagnostic descriptions and classifica- discoveries he will make, the appearance of new tions, but one should not forget that this diagnos- criminal cases committed against children, once tic has very broad margins of application. It arose more bring to the fore his inner conflicts, lead- after the Vietnam War to respond to the many ing him to act increasingly more obsessively, so cases of soldiers who displayed the psychologi- that he will start to disregard any legal or moral cal and emotional consequences that fighting in limit that might curb his own behavior. He thus re- the war had caused in them. It was formulated peats his behavior from the time when he worked as a diagnosis to group reactions that showed undercover in the narcotics squad, including sub- certain similarities. Even so, the effect of war and stance abuse and participating in violent actions. the traumatic experiences suffered always has an His disciplinary suspension from the force leads individual background due to each individual’s life him to follow a path towards increasing isolation baggage, and is expressed in differing intensity, in which he pursues his own individual investiga- characteristics and recovery capacity. True De- tion, meanwhile establishing a continued pattern tective seems to place the final accent on capac- of alcohol consumption that is abusive and self- ity for individual recovery, despite the succession destructive. of traumatic events, and their intensity and dura- Throughout the narration, references appear tion. It also focuses on the way they affect the to the perceptions Cohle has at different times, character. Perhaps too, they put one in mind of formulated as a perception disorder known as another evolution, more of a definitive collapse, or synesthesia. He defines it as “a misalignment of of prosecuting risk behaviors that lead to him rec- synaptic receptors and triggers… alkalis, colors, ognizing he is incapable of committing suicide. and certain metallics. It’s a type of hypersensi- Meanwhile we would emphasize that the se- tivity. One sense triggers another sense. Some- ries does not provide any information on the times I’ll see a color and it will put a taste in my treatment or treatments Cohle undergoes during mouth. A touch, a texture, a scent can put a note his hospital admission, though it is plausible to in my head.” Nevertheless, in a certain scene a assume that he was on a detox program linked perception appears that insinuates hallucinatory to the substance abuse and addictions that re- content, as when, from the car in which he is sulted from his time in the Narcotics division. traveling, he sees a girl waving at him, leading Let us now look at the character of Hart, an in- him to ask Hart if he believes in ghosts. dividual with no special biographical background Cohle sustains his life continuity in a life philos- worth mentioning. As the series opens, he is mar- ophy that gives him a certain rationalization, sta- ried with two daughters, and his family situation bility and strength to face his own self-destructive seems to be following a track displaying no sig- impulses. He bases it on relevant authors and nificant elements. However, winds of unease ap- texts, summarizing as: “I’d consider myself a real- pear to be blowing in the figure of his wife Mag- ist, alright? But in philosophical terms I’m what’s gie. This family environment will be progressively called a pessimist. ... Means I’m bad at parties.” affected by Hart’s involvement in the case he has He believes “human consciousness is a tragic been assigned. The character’s slow involvement misstep in evolution. … We became too self- in a storyline full of dark aspects, which gradually aware … programmed with total assurance that reveal a chain of ritual crimes whose victims are we are each somebody, when in fact everybody’s the young and the innocent, little by little increase nobody. … And I lack the constitution for suicide.” his emotional tension. This experience ends up

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Medicine in Television Series

causing him to indulge in compensatory behav- ing a series of ritual crimes in which children iors, such as drinking more, and marriage infideli- have been maltreated and murdered, can affect ties. Both sorts of behavior seem to have the aim the mental and emotional balance of a “normal” of an emotional release for him, but also of family subject, unleashing a series of behaviors that end preservation. However, they end up unleashing up destroying the life project that this person has the opposite effect: a distancing from his family, been building. about whom he is less and less concerned, and The series’ development reveals a well-formed Maggie leaving, because she does not accept his narrative. Nick Pizzolatto’s script shows a consis- affairs. Likewise, his behaviors in and outside the tent narrative thread that gives coherence to the home become increasingly violent, particularly whole of the production, in particular in relation when he kills a detainee, as well attacking two to the lead characters’ psychological character- young men in the police station who had been istics. They offer us descriptive elements of his having sex with his adolescent daughter. This sit- personality traits and biographical data on which uation goes through two different phases. In the his behaviors and reactions may be based. The first, Maggie throws him out, and only accepts evolution of events and the protagonists’ involve- him back after he has undergone a process of ment and behaviors maintain a clear connection giving up alcohol and attending relationship ther- with the opening scenes and their biographical apy. However, a new affair leads to their definitive background. break-up as a consequence of Maggie’s con- The references to clinical and psychopatho- scious choice to be unfaithful with Cohle in a situ- logical aspects fall within the acceptable margins ation she provokes. Later it is revealed that she of professional descriptions. In this way, they manages to re-orientate her and her daughters’ help to understand the behaviors and to offer lives in a new marriage, from then on appearing an understandable view of the responses of the as Mrs. Sawyer. individuals subjected to especially stressful or Hart’s character does not display precise psy- traumatic conditions, both in the personal and chopathological characteristics, but personality professional sphere. On the whole, the series en- traits that in habitual contexts rather characterize ables a humanized approach to the characters him as a person with social skills, who is funny and a certain degree of identification with them, and quite an extrovert. He has no particular in- attuning to their transformations and suffering. terests beyond his family life and social relation- This means that even their most unsuitable be- ships, both in and outside work. Nevertheless, haviors or psychopathological references do not subjected to a stressful situation, as occurs have a stigmatizing effect. with the investigation to which he is assigned, The scarce references to therapy procedures he starts a process whereby his emotional ten- in the series does not enable an evaluation of sion progressively rises, and increasingly violent their suitable or correct nature, though at certain behaviors appear that compromise his family moments explicit mentions to couples therapy, project. The increase in emotional tension due to detox measures or therapy groups appear. the investigation and the discoveries as they are The series analyzed provides a description of revealed leads progressively to a situation of a evil through criminal behaviors of diverse natures, lack of control and non-governing of his own be- the product of a serious personality disorder in haviors, which are increasingly orientated toward which the notion of rules or limits does not ex- obtaining immediate compensations through the ist. Only the satisfaction of one’s own desires and consumption of alcohol or extramarital sexual needs prevails, linked to perverse content. Nei- experiences. These are elements he describes ther does the character have the notion of guilt as essential, or rather, as the result of a need to as an element in the service of self-control and awaken his mind and get some relief. reparation. Evil is also depicted as an expression In any case, the series shows us in what way of revenge and as a path that leads to confronta- a progressive stress situation, such as confront- tion culminating in self-destruction.

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Nevertheless, what is perhaps worth high- via healthy relationships in order to evolve toward lighting from the series are those figures that, those milestones that carry them toward their life departing from different personal characteristics, goals. We would also stress the importance that are attracted to and even fascinated by the evil the series grants the relationship between both they have come across in their professional lives, characters: highly conflictive at different times, in its specific manifestations, which the case is but which plays a significant role in their per- investigating. They are characters both fragile sonal recovery. The friendship that binds these and also provided with the necessary strength characters exists within a relational and affec- to equip them to rebuild their lives and create tive framework that endows them with humanity, fresh personal projects. They are capable of be- enabling them to develop capacities for each of ing reborn through their confrontation of crime their recoveries, and on which their capacities for and violence, and of building a contention dike resilience also lie.

-116- Notebooks of the Esteve Foundation Nº 42

Polseres vermelles and Cancer

Pere Gascón i Vilaplana

This Catalan production, created in 2011 by Albert Espinosa and directed by Pau Freixas for TV3, is one of the few that has successfully made the leap, first to Spanish national TV (a dubbed version aired on Antena 3), and later, thanks to Steven Spielberg, onto the complex international circuit. He decided to adapt it for the US market, but with scant success: Red Band Society foundered in its first season from poor audiences. Nevertheless, this series about a teenage gang formed in a hospital’s corridors is an un- doubted success; it became a true phenomenon, reaching beyond the limits of the small screen.

Polseres vermelles (Red Wristbands) is a TV3 se- Despite the fact this is a drama and describes ries created and written by Albert Espinosa, and the day-to-day life of these young hospital in-pa- directed by Pau Freixas. It first went to air in 2011. tients in detail, the series is infused with humor The original script is based on the novel El mundo and constitutes a true homage to the values of amarillo (The Yellow World), of which Albert Es- friendship, companionship, life and the desire to pinosa is likewise the author. The series, which live it –to get cured so as to enjoy it. All these falls within the medical drama genre, lasted two ingredients are treated with great sensitivity and seasons with a total of 28 episodes, 13 in the first an exceptional degree of tenderness that means season and 15 in the second. It tells the story of that practically all the episodes contain scenes, six adolescents between ten and 17, who are all situations and actions that ensnare viewers in staying in the pediatrics ward of a hospital where such a way they manage to cause an emotional they have been admitted for different illnesses: impact. two have cancer in their leg bone, a type of can- So what is an oncologist’s impression of the cer requiring amputation as part of the treatment; series after having watched all 28 episodes? Per- another is in coma; a fourth has a heart problem; haps the simplest way of approaching the sub- a fifth has Asperger’s syndrome, and the sixth is a ject I have been assigned is to identify the series’ girl who suffers from anorexia nervosa. These are different medical aspects and analyze them one the main characters. Other young patients, suf- by one, from the perspective of cancer. So I will fering from various illnesses, make appearances analyze the setting where the action takes place, throughout the series. They include one with leu- the hospital, and its health personnel: doctors, kemia and a girl with breast cancer, but the latter nurses and orderlies. How do they relate to the two do not belong to the Red Band Society. One patients? What is their attitude to cancer, espe- of this series’ quirks is that children or adoles- cially when faced with a patient, in this case an cents dominate the entire action. Doctors appear adolescent with the disease? What support do when necessary, but do not take the initiative they offer the patient to continue his or her daily and, to a certain extent, always trail behind the life while undergoing treatment? Do staff indulge young peoples’ activities. The term “red band” in dramatics, or present the reality, however comes from the red wristbands that are attached tough, and help patients to manage it? Since it is to patients’ wrists when they enter the operating a fiction, parallel storylines obviously appear that theater or are given blood transfusions. are not necessarily concerned with cancer.

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Let us start with the hospital. At first, it seems that although her brother never talks about this like a children’s hospital, but immediately adult subject it would be good, sometimes, for some- patients appear who speak to the children and one to stop being so politically correct and to talk adolescents in the pediatrics wards. To thor- about death, to discuss it openly. oughly confuse viewers, at one point in the se- Fortunately, nowadays many people win the ries, a family member of one of the adolescents battle against cancer and can often discuss it is admitted to ER for birth pains and gives birth normally. This was unthinkable just three decades in the same hospital. Nowadays this type of hos- ago. There are also patients who want their con- pital no longer exists, at any rate not in Spain. dition to be explained clearly. This is Lleó’s case. Since child and adolescent pathology is so differ- He gets irritated because he thinks that life has ent from adult pathology, and even cancer types not treated him too well and confronts the doc- do not match adult types, children’s hospitals tor when the latter tells him that his disease has have been created. Another aspect of the series returned again upon finding a spot on his lung: that does not follow hospital regulations is mixing − “A spot on the lung? You mean it’s a tumor, patients of different sexes in the same room. In right?” the series, this occurs twice. A teenage boy with bone cancer and a young girl with breast cancer − “Yes, of course.” are put in the same room. − “Well, fuck, call it a tumor! I’m sick of doc- As was mentioned in the introduction, only tors befuddling me. I don’t want to receive four of the characters appearing in the series any more treatment. Twenty-three cycles are have cancer: Lleó and Jordi, cancer of the tibia; enough. That much chemo is going to leave Rym, breast cancer; and a young boy with Down me sterile.” syndrome who has leukemia. Only two belong to the Red Band Society, Lleó and Jordi, who re- This is the attitude of an adolescent who is quire amputation of the leg. The treatment, from battling between life and death, and has lost a the medical viewpoint, is quite correct. Luckily, leg. Now it appears the tumor has become resis- nowadays, most adolescents can avoid amputa- tant to chemotherapy. Nevertheless, he is wor- tion of the leg through a combined treatment of ried about becoming sterile, not about death. chemotherapy, radiotherapy and surgery. He refuses to think he might die, but obviously It should be noted that one goes into hospi- thinks about it constantly. One scene in the se- tal in a mental state that is highly conditioned by ries also exemplifies the stigma that having can- one’s illness. You are living in a strange setting, cer represents for many patients, and for adoles- with a huge emotional impact, and your emotion- cents in particular. Lleó says to Jordi: “We have al state undergoes many fluctuations depending to be brave when we leave the hospital and not on the results of tests and treatments. A patient be worried they might see us as legless”. This affected with cancer realizes, perhaps for the first “shame” of how they might be seen occurs more time in their life, that they are vulnerable. It is a frequently than we might imagine. It should not state they have entered in a matter of a few days be like that, since the disease is not the patient’s or even hours, and because of this they begin to fault. It is partially the sign, the manifestation that realize they might die. Even so, in the series little “I have or have had cancer”: the amputation of is said, or said openly, on the subject. This could a leg, the amputation of a breast. But it is also a be because it is an adolescent community that problem of image and self-esteem. If this is tough has difficulty comprehending the true meaning of for an adult, imagine what it must be like for an that irreversible loss called death. This aspect is adolescent. exemplified in the words of Lleó’s sister, when she Another aspect the series deals with is denial, comments that she always thinks and is afraid of represented by Jordi. A lump appeared in his the fact she might lose her brother. She declares armpit a year ago. He does not tell his mother or

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Medicine in Television Series

visit the doctors in hospital, though they told him at each other and one tells the other, “you nev- that at the slightest sign he should go and see er have a solution for everything”, after hearing them. He thinks or wants to believe that it is noth- Lleó’s answer that he wants to reject any other ing. This is a very common attitude, denying the treatment. This is an aspect to bear in mind in symptoms, the signs our body gives us, which oncological treatments. We all want the patient we often try to justify with many absurd excuses. to keep accepting treatment, but sometimes the Denial is a very typical reaction in people who doctor must perform an act of humility and ac- suspect deep inside that those anomalies could cept that they can no longer help the patient ac- be the appearance of cancer. tively. So perhaps they must accept that the time One aspect that in my view is not dealt with remaining to the patient is spent with the opti- carefully and lapses into stereotypes, is the vom- mum quality of life they can provide. In this sense, iting and nausea induced by chemotherapy. Lleó is brave and decides he wants to be free, Even if this was true over 20 years ago, we can even if only for a short time. He is absolutely en- now say that medication exists that has practi- titled to think and act in this way, and the doctors cally eliminated these secondary effects which accept that decision. gave chemotherapy such a bad press. While it The case of Rym, suffering from breast can- is possible for someone to vomit during the first cer, is very well dealt with from the oncological cycle of chemotherapy, if there is good doctor/ viewpoint. She looks in the mirror before going patient communication, the treatment pattern into surgery and, in homage, carefully examines can be modified to avoid vomiting and nausea the breast she will never see again. The doctors in later cycles. We must overcome this stigma tell her what the operation will be like and what about the treatment because it does not help pa- will happen afterward. She is a strong girl and tients. Chemotherapy has other adverse effects, accepts this stoically. Doctor/patient information but nowadays vomiting is very well controlled. I and communication is fluid, normal, and the as- would like to stress this because this association pects of the cancer are touched upon with the of chemotherapy and vomiting means many pa- seriousness the situation demands, but without tients begin to vomit the moment they see liquid dramatizing at all. going into their veins, believing it is chemothera- The doctors’ explanatory dialogs with the py when in fact it is only the initial saline solution, adolescents’ parents and with the patients them- or anti-vomiting medication. selves are also very well scripted. There is time An important theme in the series concerning for explanation and comment in a relaxed atmo- cancer is that of respecting the patient’s decision. sphere. This is exemplified in the episode where the doctors tell Lleó that his illness has spread to several parts of the body and he only has a 3% chance of Conclusions living. He decides to throw in the towel, to go off In conclusion, this series has been produced with chemo and leave hospital to live the time remain- exquisite sensitivity, using talented adolescent ing him freely. The doctors tell him: actors. The subject of cancer is dealt with natu- − “You know that if you go off it, you will defi- rally, without sacrificing the disease’s seriousness nitely die?” at any time. Throughout its 28 episodes, it covers the aspects of the patient/doctor relationship − “Yes, I know, but I don’t want to die in captiv- and how the news is given to the patient and his ity. I want to be free as I am, but free.” or her family environment. All this is dealt with The two doctors who have told him about the very correctly in medical terms. Cases of denial relapse and the seriousness of the situation act of symptoms or diagnosis are shown, while the correctly and humanely, avoiding a situation of patient’s desires are accepted, and dysthanasia dysthanasia (artificial extension of life). They look is avoided. The term “cancer” and its contents

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are de-stigmatized. The series does fall into the nonetheless draws the short straw. They may stereotype of associating chemotherapy and have drawn illness or health, enjoyment or suf- vomiting, a situation that is less common all the fering. The series has an extraordinary educa- time, dramatization of which does nothing to help tional component in terms of instilling values in future patients who must undergo anti-cancer children and adolescents. I stress this because, treatments based on chemotherapy. The series unfortunately, this effect is being lost and becom- is set in a hospital atmosphere where life or death ing diluted in the great mediocrity of many of the situations occur in each episode. Therefore, how programs that the communications media of- characters and dialog are dealt with is significant, fer us. “Don’t be an egoist. Life is not just yours in a setting where, though superficially it appears but belongs to everyone who loves you as well”, that everybody is happy, in truth there is a con- says one patient to another. The line reminds us trolled degree of continual tension, which peaks how far we are from such simple yet undeniably at a certain point in the series. powerful values. The series offers a little of every- The series is an ode to the humanity we all thing, despite being a drama in the fullest sense. carry inside, to friendship, companionship and It emanates both tenderness and harshness, joy the treasure of being alive. It constantly moves in and suffering, in a similar way to the daily pat- this biological and mysterious balance between terns of our lives. It is little wonder that the series life and death that can sometimes be cruel be- has attracted such a powerful following among cause it functions like Russian roulette –a game young people, but we know it has also managed of chance one has not entered, but in which one to move older people deeply as well.

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Guardiola E, Baños JE. Eponímia mèdica catalana (II). Quaderns de la Fundació Dr. Antoni Esteve, Nº 22. Barcelona: Fundació Dr. Antoni Esteve; 2011. 23. Mugüerza P. Manual de traducción inglés-español de protocolos de ensayos clínicos. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 23. Barcelona: Fundación Dr. Antonio Esteve; 2012. 24. Marušic´ A, Marcovitch H, coord. Competing interests in biomedical publications. Main guidelines and selected articles. Esteve Foundation Notebooks, Nº 24. Barcelona: Esteve Foundation; 2012. 25. De Semir V, Revuelta G, coord. El periodismo biomédico en la era 2.0. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 25. Barcelona: Fundación Dr. Antonio Esteve; 2012. 26. Casino G, coord. Bioestadística para periodistas y comunicadores. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 26. Barcelona: Fundación Dr. Antonio Esteve; 2013. 27. Carrió M, Branda LA, Baños JE, coord. El aprendizaje basado en problemas en sus textos. 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Barcelona: Fundación Dr. Antonio Esteve; 2014. 33. Gallego Borghini L. La traducción inglés-español del a informado en investigación clínica. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 33. Barcelona: Fundación Dr. Antonio Esteve; 2015. 34. Casino G. Escepticemia. Una mirada escéptica sobre la salud y la información. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 34. Barcelona: Fundación Dr. Antonio Esteve; 2015. 35. De la Torre T, coord. La medicina en las series de televisión. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 35. Barcelona: Fundación Dr. Antonio Esteve; 2016. 36. Hernández I, coord. Definición de prioridades en políticas de salud. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 36. Barcelona: Fundación Dr. Antonio Esteve; 2016. 37. Mayor Serrano MB. El cómic como recurso didáctico en los estudios de Medicina. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 37. Barcelona: Fundación Dr. Antonio Esteve; 2016. 38. Guardiola E, Baños JE. Eponímia mèdica catalana (III). Quaderns de la Fundació Dr. Antoni Esteve, Nº 38. Barcelona: Fundación Dr. Antonio Esteve; 2016. 39. Claros Díaz MG. Cómo traducir y redactar textos científicos en español. Reglas, ideas y consejos. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 39. Barcelona: Fundación Dr. Antonio Esteve; 2017. 40. Revuelta G, Morales P, coord. Debate sobre periodismo científico. El tratamiento informativo del brote epidémico del virus del Ébola. Cuadernos de la Fundación Dr. Antonio Esteve, Nº 40. Barcelona: Fundación Dr. Antonio Esteve; 2017. 41. Valls R, Bigorra J, coord. Philanthropy in research and innovation in biosciences. Esteve Foundation Notebooks, Nº 41. Barcelona: Esteve Foundation; 2017.

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Television fiction viewed from the perspective Medicine in Television Series of medical professionals

House and Medical Diagnosis. Lisa Sanders Editor: Toni de la Torre The Knick and Surgical Techniques. Leire Losa

The Sopranos and Psychoanalysis. Oriol Estrada Rangil

The Big Bang Theory and Asperger’s Syndrome. Ramon Cererols

Breaking Bad and Methamphetamine Addiction. Patricia Robledo

Mad Men and Tobacco Addiction. Joan R. Villalbí

The Walking Dead and Epidemics in the Collective Imagination. Josep M. Comelles and Enrique Perdiguero Gil

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series. Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Nip/Tuck, Grey’s Anatomy and Plastic Surgery. María del Mar Vaquero Pérez

Masters of Sex and Sexology. Helena Boadas

CSI and Forensic Medicine. Adriana Farré, Marta Torrens, Josep-Eladi Baños and Magí Farré

Homeland and the Emotional Sphere. Liana Vehil and Luis Lalucat Series Medicine in Television

Olive Kitteridge and Depression. Oriol Estrada Rangil

True Detective and the Attraction of Evil. Luis Lalucat and Liana Vehil

Polseres vermelles and Cancer. Pere Gascón i Vilaplana

ISBN: 978-84-945061-9-2 9 788494 506192 42