Abundance: A Review in Family Medicine

By Raymond Downing, MD
Family Medicine
February 2020

Abundance is a well told tale, part drama, part adventure thriller, set both in Liberia at the end of 14 years of nearly constant civil war, and in Rhode Island, where most of the characters have some connection. Julia, a 32-year-old doctor with experience in several third-world hot spots, is kidnapped as the long-standing war makes a final gasp. Carl, a water engineer with a past he’d rather not discuss, realizes just as he is being evacuated that he is probably in love with Julia. Back in Rhode Island, he engineers an improbable return to Liberia to rescue Julia. He brings with him Terrance, a Liberian former child soldier, and Bill, a sixty-something, nearly-burned-out political activist ER doctor who also knew Julia.

I occasionally enjoy a thriller movie with a car chase and clever plot twists, which this novel provides. Michael Fine, MD, a family physician based in Rhode Island, drew from a short-term medical mission to Liberia in 2009 as he wrote. But beyond just an adrenalin-pumped, sound-cranked-up entertainment, this novel provides insights into the emergency medical aid industry, and especially who we expatriate aid workers are, what we fear, and what we hope for.

Who we are. It’s an open secret that global health workers have mixed, and even selfish, motives for their work. “Julia loved desperate places, the places where there was nothing and where the people had no one, so they took her for who she was, as she was, and didn’t ask her the questions she couldn’t answer for herself.” All the relief workers Fine describes are passionate, but most of them are unhappy at home, and feel in Africa a sort of freedom they never experienced back home. For Carl, “Africa was life itself, while home sucks your soul away.”

But more than being vividly alive, expat aid workers set their own agendas. “In the compound, Carl was in charge… was all command and control.” Especially for those who work in failed states, we run the show, and there is little opportunity to develop equal relationships with local or national peers, to be their employees, to learn from them.

What we fear. Our fears are undoubtedly individual; mine include motor vehicle accidents and kidnapping. Some of these fears appear in our writings. Therese Zink’s Mission: Chechnyafeatures a kidnapping1 as does my own global health novel.2 We may be simply admitting our fears, though perhaps for us, kidnapping serves as a metaphor for this push-pull that Africa exerts on us. Years ago a doctor I worked with, formerly a Peace Corps worker in Botswana, admitted that though he loved working in Botswana, he was afraid that if he didn’t return to the United States soon, he never would be able to. He felt the risk of being psychologically kidnapped. However, Fine does not point to any metaphoric meaning, and seems to use the kidnapping for its thrill value, and the rescue as a beginning for the sorting out of Julia’s “questions she couldn’t answer for herself.”

What we hope for. Fine’s characters, and perhaps Fine himself, are repeatedly trying to articulate what this global health helping is all about. Julia, quoting her mentor Bill, remembers him saying “If you save one life, you save the world.” Yet Bill later admits: “What kind of idea was that? What does it mean to save a life? What arrogance!” Another of Bill’s nuggets was: “Medicine is unself-interested advocacy,” and fantasized “Julia was the real thing. Julia was repairing the world, saving lives…” Later, in captivity, Julia reflects: “That shit got me locked up. All that unself-interested crap. That is what brought me to Africa… That crap is going to kill me.” Carl explores the dilemma with more of a political view: “Development brings more stuff, more goods, and more guns. More wanting. Wanting brings war.”

A final irony is the book title. Some of these characters find abundance of life in Africa. Yet Carl’s statement above reveals the other side of abundance: more stuff, more wanting, and more war.
This is a novel, an adventure story, and as such it succeeds. However, the characters’ motivations and hopes, while quite realistic, are more disturbing in the larger context of global health. Some of us come to escape, to sort out our own problems. Others come to help, and thinking we know what help is needed, we impose our own solutions. In Julia’s thinking, “Together we make abundance, even as this abundance fuels the fires that tear us apart.”