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The Arts and Medicine
June 26, 2020

Rereading Arrowsmith in the COVID-19 Pandemic

Author Affiliations
  • 1Department of Otorhinolaryngology–Head and Neck Surgery, University of Maryland School of Medicine, Baltimore
JAMA. 2020;324(4):319-320. doi:10.1001/jama.2020.11489

You should read Arrowsmith,” I have long told aspiring clinician-scientists I interview, as a way of getting them to think about which of the 2 career tracks drives them more. That recommendation is even more timely and broadly relevant now in the midst of the novel coronavirus disease 2019 (COVID-19) pandemic.

The 1925 novel by Nobel Laureate Sinclair Lewis tells the story of Martin Arrowsmith, an ambitious early-career physician who finds himself drawn to research but gathers no moss as he tries out roles as a clinician, scientist, and public health specialist, seeking models and mentors at each turn and finding them all unworthy of his ideals. He finally finds a home as a researcher at a well-funded private institute in New York when a novel bacteriophage treatment he has developed seems like it might be the cure for a fictional bubonic plague outbreak ravaging a Caribbean island. In the face of the deadly epidemic, his principled commitment to maintaining a control group to prove the efficacy of his therapy is barely sturdier than the sense of superiority he has carried his entire life, and the widespread death he encounters on the island forces him to choose between his ideals and identity as a scientist (studying the treatment first) and as a humanitarian and clinician (treating everyone). It takes what may be the only fate worse than dying in a pandemic to shock him into a direction, and it is left to readers to judge the merits of his choice, which in the end disappoints even Arrowsmith himself.

Although never explicitly stated, the work was clearly influenced by the influenza pandemic of 1918 and was awarded the 1926 Pulitzer Prize for Literature, which, with Arrowsmith-like idealism, Lewis turned down on principle.

The author worked closely on the novel with Paul de Kruif, a then-prominent bacteriologist and author of the wildly popular Microbe Hunters (a 1926 hagiography of early microbiology researchers). De Kruif’s input gives Arrowsmith a striking realism with a host of characters readily familiar to 21st-century practicing and academic physicians. The fictional Almus Pickerbaugh, a regional public health director, could be a Twitter influencer today, believing and persuading others that “because he was sincere, therefore his opinions must always be correct” (chapter 21.2), and focusing more on style than substance. Martin Arrowsmith’s ultimate mentor is the tyrannically honest and scientifically uncompromising Max Gottlieb, who would “rather have people die by the right therapy than be cured by the wrong” (chapter 12.1). There are non–data-driven, money-obsessed physicians like Roscoe Geake, an otolaryngologist who feels that a surgeon who would choose not to remove the tonsils of any patient was “foully and ignorantly overlooking his future health and comfort—the physician’s future health and comfort” (chapter 8.1). There are numerous, all too familiar, compromising and shallow bureaucrats. And Martin Arrowsmith’s inability to find his place or distinguish heroes from charlatans is matched only by his lack of social skills and diplomacy, reminiscent of Larry David in Curb Your Enthusiasm.

But the delight and comfort we might take from seeing a send-up of our professional communities in great literature turns unsettling given the persisting challenging behavior and unknowns that traverse the century since the novel was written. We read of social distancing born of fear rather than concern for others, denial of the reality of infection, economic and political objections to quarantine and other top-down proclamations (chapter 31.3), and of distrust of unproven claims for the value of face masks in influenza epidemics (chapter 21.2). The book tells of early therapeutic interest in antibiotic properties of quinine derivatives, and we read about the same rush to recommend them before completion of adequate testing (chapter 38.1-2). One character offered Arrowsmith’s potential cure honorably insists, “I will not touch it till you…give it to everybody” (chapter 31.3). How many of us would or did take hydroxychloroquine recently at the first sign of a cough, or even after testing positive, despite lack of evidence for its efficacy and the public health risk of such widespread behavior creating a national shortage for those who already depend on it?1 It is indeed humbling to see history repeat itself without our having resolved some fundamental scientific unknowns or learned some of its most important lessons. Reading Arrowsmith now we are humbled, if not puzzled, that so many of the same questions remain unresolved.

The novel also tackles research ethics questions still relevant today, as the challenges Arrowsmith faced trying to maintain the scientific integrity of his clinical study during a pandemic have again become all too familiar. What is the role of compassionate use and emergency authorization when we desperately need to demonstrate what is effective and harmful for treating COVID-19?2,3 The sincerity both of clinicians hesitant to withhold promising though untested therapies from their patients and of those strongly advocating for the importance of controlled trials cannot be doubted. Arrowsmith exemplifies the conflict, swearing initially “that he would not yield to a compassion which in the end would make all compassion futile” or be “tempted to…give up the possible saving of millions for the immediate saving of thousands” (chapter 34.1). As he sets off to test his experimental therapy, Gottlieb exhorts him:

Be sure you do not let anything, not even your own good kind heart, spoil your experiment…. I do not make funniness about humanitarianism…; sometimes now I t’ink [sic] the vulgar and contentious human race may yet have as much grace and good taste as the cats. But if this is to be, there must be knowledge (chapter 32.3).

This conflict between learning and doing3 has always hovered quietly over clinical research, roaring back now in the COVID-19 pandemic, and in Arrowsmith, the commitment to scientific integrity is easier made than honored. Perhaps we should be reassured that we are rethinking things a century later, but reading the novel now provokes at least as much frustration that we have not learned from the past.

Despite these frustrations, Arrowsmith provides a long view of the challenge. Medical and scientific knowledge were far less advanced in the early 20th century, and yet both the real influenza and fictional plague pandemics ended. Despite many scares and some horrific outbreaks, we have not had such a widespread and indiscriminately transmissible outbreak since 1918. That historical perspective makes it possible to retain some optimism, even in the face of conditions we have not experienced in a long time and in the face of a halting or disorganized national public health response that seems as if it could have made things worse. That alone is a good reason to re-read Arrowsmith now.

Poster for the film Arrowsmith (United Artists Pictures, 1931).

Source: Wikipedia.
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Article Information

Corresponding Author: David J. Eisenman, MD, Department of Otorhinolaryngology–Head and Neck Surgery, 16 S Eutaw St, Frenkil Bldg, Ste 500, Baltimore, MD 21201 (deisenman@som.umaryland.edu).

Published Online: June 26, 2020. doi:10.1001/jama.2020.11489

Conflict of Interest Disclosures: None reported.

References
1.
Manson  K. Virologist behind “Contagion” film criticises leaders’ slow responses. Financial Times. April 19, 2020:FT Weekend page 3.
2.
Kalil  AC.  Treating COVID-19–off-label drug use, compassionate use, and randomized clinical trials during pandemics.   JAMA. Published online March 24, 2020. doi:10.1001/jama.2020.4742PubMedGoogle Scholar
3.
Angus  DC.  Optimizing the trade-off between learning and doing in a pandemic.   JAMA. Published online March 30, 2020. doi:10.1001/jama.2020.4984PubMedGoogle Scholar
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    7 Comments for this article
    EXPAND ALL
    Worthy Recommendation
    Sally Dellas |
    Thank you for recommending a reread of Arrowsmith. I read it many years ago and found it absorbing. I don’t want to reveal any of the plot, but I will never forget Leora.

    I hope that those who may never have had much contact with Lewis’s work will be inspired to read more of him. I am now reading “Free Air” off my iPhone while in waiting rooms. I had never heard of it before but I find it entertaining in its use of quaint slang terms, the conditions of roads back in the twenties, and references to “politically
    incorrect” customs and attitudes of those days.

    Now I intend to read Lewis’s “It Can’t Happen Here,” because I believe that it HAS happened.

    I appreciate your comments on similarities between the present and the situations and characters in the novel.

    Sally Dellas
    CONFLICT OF INTEREST: None Reported
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    Sinclair Lewis Has Much To Teach Us
    Tina Castanares, MD | Retired Family Physician, Hospice and Palliative Care Specialist, County Public Health Officer
    This is a fine piece and I share the author's recommendation to read or re-read Arrowsmith. But even more strongly do I recommend a read or re-read of Sinclair Lewis's It Can't Happen Here, about the election of an unqualified celebrity American president co-opted by a radical fundamentalist and anti-government base, which ironically drifts quickly into full fascism.
    CONFLICT OF INTEREST: None Reported
    Coincidentally...
    Lisa Kearns, MS | Division of Medical Ethics, NYU Grossman School of Medicine
    My friend and colleague J. Russell Teagarden published an article on May 29, 2020, called "Reading Arrowsmith During the 2020 Pandemic," in which he drew parallels between current quotes from government officials (chiefly the president) about the Covid-19 pandemic and text from Sinclair Lewis's work. Teagarden wonders whether "outcomes of pandemics will forever be determined by the contest between human folly versus rational and organized application of scientific methods, public health principles, and public administration fundamentals."

    Here's a link to his article: https://www.accordingtothearts.com/2020/05/29/reading-arrowsmith-during-the-2020-pandemic/
    CONFLICT OF INTEREST: None Reported
    Arrowsmith
    Gary Ordog, MD, DABMT, DABEM | County of Los Angeles, Department of Health Services, Physician Specialist (retired)
    When I was in high school I followed Jacques Cousteau and studied to be a marine biologist. Then I read Arrowsmith and decided I wanted to be like him. This led me to also apply for Medical School, medicine became my life, and marine biology continued as my hobby. The rest is history, thanks to this book by Lewis. Thank you.
    CONFLICT OF INTEREST: None Reported
    Albert Camus, The Plague (La Peste) - Timeless
    Rudy Ruggles, BS Physics & MBA Harvard | J. Craig Venter Institute, Board Member and Adjunct Scientist
    In addition to Arrowsmith, I highly recommend reading - or listening to - Albert Camus’ The Plague (La Peste). I recently finished listening to an excellent Audible reading - acting, really, because the narrator does the different voices so well. I had read it years ago when I got going on a Camus binge. Even if you, too, had read it some time ago, I assure you that re-reading it while in the midst of a pandemic will bring it to life as never before. Although written in 1947 about a small fictional town in Algeria where Camus lived that fell victim to a plague, it is amazingly prescient. The whole cycle - so clearly evident now - of denial, evasion, fear, government inaction, numb surrender, false hope, absence of medical solutions, and eventual passing of the threat is played out. The similarity to today is not a ringing endorsement of man’s improving behavior and wisdom - but little is at the moment.. 

    In 1957 Camus was awarded the Nobel Prize in Literature "for his important literary production, which with clear-sighted earnestness illuminates the problems of the human conscience in our times." I guess “our times” are still with us.
    CONFLICT OF INTEREST: None Reported
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    Summarizing "Arrowsmith"
    Vladimir Patchev, MD, PhD | ExSciMed Consulting
    Arrowsmith has been one of my favorites for more than 50 years. Dr. Eisenman’s contribution makes a bold statement worthy of being reiterated to students and young doctors.

    The JAMA summary may be slightly misleading however, having conflated two independent episodes of the novel into one. To put things correctly: a) the fictional plague therapy was a bacteriophage and not a quinine derivative; b) Dr. Arrowsmith and his colleague Terry Wickett were fired from the fictional McGurk Institute for disagreeing with the rapid introduction of certain new quinine derivatives for (not plague-related) pneumonia therapy.

    Despite these minor misstatements,
    it is intriguing to ask whether today’s idea of quinine derivative use for COVID-19 pneumonia treatment has been borrowed from the episode described in Arrowsmith.
    CONFLICT OF INTEREST: None Reported
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    Arrowsmith and Sincerity
    Joseph Kaempf, MD | Providence Health, Women and Children's Services, Portland OR
    Excellent humanities piece from Dr. Eisenman, and I will order Arrowsmith today.

    The "sincerity" comment was spot-on. 'Sincerity’ is increasingly co-opting reason and rational evidence in our media-saturated society,…..i.e., apparently if you ‘sincerely believe’ something you are permitted an unchallenged, semi-factual, biased position, and thus liberty to foist as ‘truth’. It is a deeply worrisome trend, in healthcare and other disciplines.

    Who pointed this out brilliantly and concisely of recent? Harry Frankfurt in his exquisite "On Bull***”,....and the intellectually-similar, oft-forgotten “True Believer” by Eric Hoffer, a neglected masterpiece of insight from 1951.

    Joe Kaempf,
    MD
    Portland, OR
    CONFLICT OF INTEREST: None Reported
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