Sarah Moss interview transcript


4 December 2017

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> Introduction 

Ray Moynihan: Iona Heath is a brilliant British doctor who's inspired me and many others around the world. She's also a writer and author, a regular contributor to the British Medical Journal, BMJ, and someone who seeks her evidence from literature as much as from systematic reviews of studies, but today's episode of The Recommended Dose is not about Iona Heath.

A few months ago, I was hungry for some good fiction and I emailed Iona for suggestions. She immediately came back and suggested the novels of Sarah Moss. Iona told me how she had just read all of Sarah's work and loved it, so I started doing exactly the same thing and immediately fell in love with her novels as well. I also discovered that Sarah Moss has got much critical acclaim. She's won awards and is being hailed as one of the best British novelists writing today, and several of her novels engage very directly with medicine and healthcare in surprising ways. So I'm very pleased to say that Sarah Moss is our guest today on The Recommended Dose with me, Ray Moynihan.

Ray Moynihan: Welcome Sarah Moss.

Sarah Moss: Thank you.

Ray Moynihan: I think you've described a writer's role as, "Asking hard questions beautifully." 

Sarah Moss: Yes.

Ray Moynihan: And I'm finding that your books do that, but they do it with humour and great stories as well.

Sarah Moss: Thank you.

> Fiction and medicine |  Research for writing | Origins of interest in health and medicine [1 min 32]

Ray Moynihan: Let's talk a little about medicine. While doctors and medical technology tend to turn up fairly often enough in books and TV shows and films, it's rare, I think, to see healthcare dealt with so intelligently the way you do. How is it that the world of medicine has emerged as one of the important parts or aspects of your work, why is that?

Sarah Moss: I don't really know. I mean, I get asked that one fairly often, and I used to say I don't think it's that I'm particularly fascinated by medicine so much as that I'm ... Any novelist is fascinated by the crises in life, the most obvious ones being birth and death, and the fear of death, and those are moments that happen in the context of healthcare. I mean, you know, if you're approaching a real crisis in your life, there's usually somebody in a white coat in the immediate vicinity. I mean, of course that's not the real answer because novelists would write about nothing but healthcare if that were true.

I think it's partly the narrative aspects of medicine. The older I get, and the more experience I have as a patient and a relative of a patient, the more it feels to me as if a lot of healthcare is fundamentally a narrative process. But I was thinking about it as I was walking over here, I was always fascinated by human biology. I didn't do very much science at school. I'm the product of a system in which you specialise very, very early, and I specialised in languages and literature, but I remember arguing repeatedly with school because I wanted to be allowed to keep taking biology while I did French and Latin and Italian and History. I wasn't allowed to in Britain at that point, you had to jump one way or the other at 14, and it was clear to me which way I was jumping, but I think that interest in biology, in human biology, in the body, never really went away.

And then when I was doing my PHD I lived in a house full of postgrad medics. Looking back, that probably wasn't coincidence. I mean, there weren't very many English Lit PhDs whose friends were all medics. And that meant that I got a kind of worm's eye view of that process of learning to be a doctor.

Ray Moynihan: A worm's eye view, did you say?

Sarah Moss: Yeah, that's what it felt like. They didn't know what they were doing. They were learning.

Ray Moynihan: This was Oxford University, was it not?

Sarah Moss: Yeah.

Ray Moynihan: I think you told me, there were copies of ... well then they would have been print versions of the BMJ in the toilet, is that right?

Sarah Moss: Yes, that's right. Well there were little post-its everywhere because they were taking exams every few weeks and accumulating very specific knowledge of very specific things, which as far as I could see then disappeared as soon as they'd done that particular exam. So there were little post-its all over the house with details about, I don't know, how to tap someone's stomach to hear what it sounded like, or what to do with a knee, or something. And I was bumbling around writing a thesis on Wordsworth, so I kept encountering these things. I'd be standing there boiling the kettle and finding that, as I moved away with my cup of tea, I knew a whole lot about...I don't know... urology, or something that I hadn't known 10 minutes earlier. 

Ray Moynihan: You knew about urology for better or worse.

Sarah Moss: Yes. Some teeny bit of it that someone was going to have an exam on next week, for which I had no context whatsoever.

Ray Moynihan: While we'll talk about medicine and your interest in it, and the way it appears in your novels through this conversation, I should stress your books are about much more than that. I mean, I think it's fair to say that they're pervaded very strongly by a sense of the importance of social justice, would you agree with that?

Sarah Moss: I hope so, yes. And again, I mean that doesn't feel to me separate from healthcare. But I'm also interested in, not protest fiction particularly, but writing that imagines ways in which the world could be different and better. Not quite sure what the point of writing would be if it didn't constitute some kind of critique of the way things are and some kind of aspiration for how they might be different.

Ray Moynihan: Before we talk about some of your books and their engagement with medicine, one of the things we talk a lot about on this program, The Recommended Dose, is evidence, and this sort of evidence based approach to medicine. And normally that's the formal evidence that arises from trials and summaries of trials and so on, but I'm imagining, I'm presuming that the sort of evidence you work with as a novelist, as a writer, is very different. Am I right?

Sarah Moss: Yeah. I suppose it's archival really. I mean, I write both fiction set in the 19th century and fiction with a modern setting. So the sort of research I do is really the sort of research I was trained for, it's humanities, social science research. I spend a lot of time in the archives. I read a lot of primary and secondary historical material. Sometimes I get to go places, that can be quite fun. You know, I spent a lot of time in Coventry Cathedral for one of my books. I've been spending a lot of time in Hadrian's Wall and looking at archeological digs for the one I've just finished, which will be out next year. So it is pretty wide ranging, and then sometimes I do find myself reading medical journals, but always with a kind of haunting awareness that I don't really know what I'm doing and I'm not equipped to follow. 

> First female doctors in Britain | The Edinburgh 7 | Obstacles to women practising medicine [6 mins 33]

Ray Moynihan: Let's talk a little bit about one of the themes, if you will, that I've divined in your work, and I think you've talked about and written about, and that is women becoming doctors in Britain for the first time in the 19th century. One of the storylines, I think, in two of your novels, Bodies of Light and Signs For Lost Children, is about the entry of women into this male dominated world of medicine in the 19th century. What sparked your interest in that storyline?

Sarah Moss: My academic interest was partly in gender and work, so that goes back to my previous career as a kind of mainstream academic. What's really interesting, I think, about women's entry to medicine and the reason it happened earlier than women's entry to the other professions, is that there's both a conservative and a radical argument for the presence of women in medicine. And the conservative argument is that if you don't have women doctors, then female patients have to display their bodies to male doctors in ways that they might find humiliating or difficult, and there was plenty of Victorian evidence that women would simply avoid seeking any kind of medical treatment because they didn't want to have to show their bodies to men. So the conservative argument was that if there were women doctors, then women would be able to have healthcare on the same standards as men without having to violate their modesty, that you could protect women's femininity, their modesty, their conservatism, without denying them healthcare. 

And the radical argument was, of course, that there's no reason why a woman shouldn't be a doctor because she'll be at least as competent as a man, but it was kind of the pincer movement of those two kinds of desire for female medics that meant, I think, that it happened some 40 years earlier than women's entry to the other professions.

Ray Moynihan: While it happened in those books, describe the way it happened, and I'm imagining that the research and indeed what happens in some of those novels also, shows the tremendous obstacles that those early women faced. Talk a little bit about what you discovered through your research.

Sarah Moss: Lots of things about it were surprising to me. The first women to qualify as doctors in Britain were called the Edinburgh Seven, and they were able to get into Edinburgh University to study medicine because there was something in the writing of Edinburgh's charter that meant that women were not explicitly prevented from matriculating. So the language around matriculation didn't specifically exclude women. It wasn't that it included them, it was just that there was a little bit of ambiguity about the gender of the students concerned. But they had a huge fight, and even once they'd got in, quite a few of the professors refused to teach them. Many of the male medical students refused to be present in a room with them. It went as far as physical violence. I mean, there were threats of rape, they had faeces thrown at them in the streets. There was one point where a building they were in was set on fire. Quite astonishing levels of harassment and violence, and they had to pay themselves for some parts of the curriculum to be delivered because the people who were teaching it in Edinburgh weren't prepared to teach women.

And then when they finally got through and took the exams, and they all did very well indeed because you can imagine only extremely driven and ambitious women were still going to be there at that point, they were told that the language which allowed them to matriculate didn't allow them to graduate. So, you know, well done, you've passed your exams, but you don't get the qualification. And they had to go abroad to re-do their exams - France, Ireland and America - before they could call themselves doctors and come back and practice. 

Ray Moynihan: Unbelievable, and what do you think was ... I mean, there were many things probably at the heart of that male fear, but what was driving that fear and those violent reactions?

Sarah Moss: Well, some of it was straightforward misogyny. It's really the beginnings of a discourse that we still sometimes see around women and professionalism, that if women were able to practice as doctors it would devalue medicine. Actually, if you look at what happens in teaching, for example, that wasn't completely wrong. As professions become feminised, they seem to become less valuable, pay drops, respect falls. There was a view that no decent woman could possibly want to see the inner workings of the human body and therefore, by definition, those who did want to were not sane, or not clean or not properly women, and therefore had no place in medicine anyway.

> The National Health Service (NHS)  [11 min 06]

Ray Moynihan: Let's go forward to your latest novel Tidal Zone, that again has a female doctor character. She's the mother of the family. She's an overworked family GP working in the British National Health Service or NHS. We'll talk about the NHS in a minute, but is that battle for equality in medicine between men and women still going today, do you think?

Sarah Moss: Well you probably honestly need to ask a doctor. I'm sure it is, it certainly is in academia. Nursing staff are still predominantly female, consultants still tend to be male, there aren't very many women in surgery. So I'm sure it's all still there and still happening. 

Ray Moynihan: While we're on the NHS, Britain's universal publicly funded health system, your novel Tidal Zone does seem to have some very potent criticisms of the NHS. Things like having to wait more than a week for a vital test in a life and death situation, the poor pay of nurses, and general sort of underfunding. Is this an issue that's dear to your heart?

Sarah Moss: Yes. I think if you asked anybody in Britain, they would say it was dear to their hearts, and that's one of the reasons why it's so interesting. Someone in the run up to the election before last called it the national religion, and I think that's probably true. I think that's because it's one of the most intimate experiences of politics. When I was going around talking about The Tidal Zone, I run, I run a lot, I run too much, so I very often have some kind of minor knee injury. And as I was getting on and off trains moving my stuff around the country talking about this book, there were times when my knees were sore, and I thought at one point, this is why we care about the NHS because I'm not bothering to tell any healthcare provider that my knee is sore because I know perfectly well why my knee is sore, it's because I'm running too much. I know they'd tell me to run less and I'm not going to do that unless it gets a lot worse. So, you know, here we go. And anyway there's no NHS funding for physiotherapy for people who run too much. 

And I thought this is why we care, because the NHS is present in my body as I lift my suitcase on and off a train, as I make a decision in the morning about whether I'm going to go running or not, and that's something tiny. You know and that's something that doesn't really impact on my life and would stop if I had the sense to stop running until it got better, which I don't.

If you think about the much greater traumas, and pains and illnesses that people carry with them, when you then hear politicians arguing about the NHS, they're arguing about what's happening inside your body, inside your brain, what's affecting how you move around your own house. And of course, politics is always immediately relevant to the citizens, but you're not always quite so sharply aware of its immediate relevance. It's not always politics twinging in your knee as you step off a train, or banging in your head when you wake up in the night. I think that's why we care so much.

> The Tidal Zone  [14 min 02]

Ray Moynihan: You're listening to a conversation with British novelist Sarah Moss on The Recommended Dose, a podcast funded by Cochrane Australia, and she's talking here about her latest book, The Tidal Zone

Sarah Moss: One of the points of genesis for The Tidal Zone was a day a couple of years ago, very ordinary morning in my house, I was trying to get the children up, I should have made the packed lunches before, but I hadn't, so I was trying to make them while I was eating my own breakfast and trying to bully the kids down, and through the shower, and out of the door. We had the Today program on, Radio 4's flagship news program, which we always do in the mornings. And they were reporting from Syria. A children's hospital had been bombed. There was a man standing in the room shouting something in Arabic, and the translator said, "He's holding his daughter's body and he's shouting, 'Where is the world? This is happening to us. Where is the world?'" I kind of froze in the middle of making sandwiches and thought, the world is here, journalism has worked, I have heard you, but I don't know what to do about it. 

And there wasn't anything I could do about it, of course. I finished making the lunches, and I got my children out of the door, and I went off to work, and had a fairly normal day. When my kids came back from school, then I said, "How was your day?" which I always say, and they said, "fine," which they always say, and I said, "what happened?" and they said "nothing," which is what they always say. Then later, one of them said, "Oh actually, the helicopter came." I said, "What?" And he said, "The helicopter came in football," and someone in his year had had a bad fall while playing football and complicated leg fracture, so they'd called the air ambulance had come to pick this child up. You can imagine there was a lot of talk about it, but the child was fine. He was in hospital for a while, but he's playing football again now. I thought, at one end of the Mediterranean, you scramble helicopters to bomb a children's hospital, and on the same day at the other end of the Mediterranean, you scramble a helicopter to pick up a child who's hurt his leg playing football so that you can take him off and treat him as well as you possibly can and get him back on the football field. I don't know how you hold those two things together. 

I know how you say, "Oh well, parents in war zones must be used to losing their children, and it's not the same thing as if it happens to my neighbour," which is an appalling thing to say. And I understand how you say, "Well, children are dying all over the world, so you've got no business complaining about your broken leg," but both of those are really inhumane responses. So I wanted to write a book that lived knowingly in the space between those two realities, that accepted that both of those things happen and both of them matter, and that it's impossible to weigh them against each other. 

Ray Moynihan: Early on in The Tidal Zone, there's a telephone call. A teenager, Miriam, has collapsed at school and her heart has stopped, leaving her parents Adam and Emma having to think the unthinkable.

Sarah Moss: For me, a lot of The Tidal Zone is about plot and structure because one of the things that's very difficult after a sudden trauma is the sense that your story is broken. You thought you knew where you were, you thought you knew which path you were on. You know the beginning, this is the middle, the end is to come, and when some inexplicable sickness or devastating event comes, the first thing you want is for the doctors to give you an answer. What is it? What is the story? A diagnosis is the story, it puts you back on a kind of narrative path. So how do you live without a story? How do you live without a narrative? Is it possible? 

One of the things you have to learn is that what happened yesterday isn't always a guide to what happens today, that you're navigating blind, and that's terrifying, but I'm interested in it as a writer. I'm interested in it as a fractured narrative, and if you accept the fracturing of the narrative, if you don't just try to put something back together very quickly and get back on with it, but say, OK the narrative is broken. We live with brokenness, we live with openness and emptiness and uncertainty, what is that like? How is it to live, and can you live well with absolute uncertainty? Or is it just about living with fear?

Ray Moynihan: And you're just here to ask the questions. 

Sarah Moss: Yep.

Ray Moynihan: You're not giving us the answer (laughs).

Sarah Moss: How could I? How could anybody? I mean, Adam comes to an answer, doesn't he? They find ways of doing things, but it is about accepting the brokenness of narrative, and then being able to move on with the pieces in your hands. 

> Mental illness | Signs for Lost Children | Postnatal depression | Domestic life | Stay-at-home Dads [18 min 40]

Ray Moynihan: I want to talk a little bit now about mental illness because I think the history of mental illness, or some parts of it, again, has been of interest to you and has appeared in your writing. You've said this about the character in your book Signs For Lost Children, Ally is a newly qualified doctor beginning to specialize in mental health in an era that was only beginning to imagine madness as treatable. Just for people who aren't aware, Ally is the same character we were talking about earlier who was at the forefront, a pioneer in terms of female medicos. I mean, can you tell us a little bit about this history of when madness started to be imagined as treatable?

Sarah Moss: I mean, Ally's probably exaggerating a bit when she thinks of herself as being among the first to imagine it as treatable because this had been happening before at the York Retreat and some of the Quaker Asylums as far back as the 18th century, but it was only really in the later 19th century in Britain where there were big publicly funded asylums for the insane or for lunatics, were usually the terms that we used. There weren't, so far as I know, actually any female, they were called mad doctors at that date, the idea of psychiatry wasn't really around. So far as I know, there were no women doctors working in mental health until the 20th century. So Ally's fictional anyway, but she's grown up feeling herself balancing on the cusp between being very driven and very ambitious and being mentally ill. She's been the scapegoat of her family, so she has a sensitivity particularly towards women's mental illness.

Ray Moynihan: I mentioned Iona Heath earlier, Dr Iona Health, she introduced me (I'm very grateful to her) to your work.

Sarah Moss: I was so impressed by her.

Ray Moynihan: I asked her what she would like to ask you, and she wanted to ask you about Ally as well in Signs For Lost Children, and Ally at another point says, "It's not that some people are so fragile that they require the permanent protection of an institution, but that some people's homes are crazier than the institutions. Some households do not tolerate sanity."

Sarah Moss: Yes.

Ray Moynihan: Can you talk to that, and how that arises?

Sarah Moss: I'm always fascinated by what we hope from institutions. I mean, I've spent my life in universities, so in some ways that's not entirely surprising. But the relationship between the nuclear family and the institution seems me to be one of the unwritten histories of the 19th and 20th centuries. I think, very often, those of us who spend a lot of time in institutions in some ways displace family dynamics, begin to look to the institution to be our parents or our siblings or maybe even sometimes our children, and I'm interested in the utopian potential of institutions. 

In The Tidal Zone, one of the characters spent a lot of time living in intentional communities in communes, which are a similar kind of response to the failure of the family. In the 19th century, you get the rise of these institutions replacing family care; orphanages, asylums, hospitals, and in some ways, I think they have so much potential. They're almost always conceived with great hope, and often love, for the people they're meant to be serving, and then they so often go so wrong. But I still like the idea that you can at least try to create institutions that can mend the harm done by families. 

Ray Moynihan: That quote from your character, Ally, goes on that, "The profession," presumably she means medicine, "Needs a definition of sanity about the boundaries of grief and rage and pain. The profession needs someone to say that some domestic homes, some families, produce madness, not by hereditary organic disorder, but by a modus operandi that requires the insanity of one of their members." Iona Heath says that these insights invite doctors and other professionals to stop situating a lot of mental illness within the individual person, but rather within the extended family, the community, or society. Iona wants to ask you, how did you realize this? Was it a feat of empathy and imagination, or a consequence of your lived experience, or a bit of both? 

Sarah Moss: Probably a bit of both, I think. I must say, I'm terribly impressed that Iona Heath likes my books, I didn't know this. I shall go off and hug myself with it the rest of the day. Both, I think. I had quite severe postnatal depression after both babies, and really felt that a completely reasonable response to an almost intolerable situation was being pathologised. I had no extended family help, neither infant slept at all for years, I found breastfeeding very difficult, and I kept thinking: I am more sleep deprived than many prisoners in regimes where they deprive people of sleep on purpose, you know... I am bleeding from places I didn't know I could bleed. I am in a lot of pain. I am going completely mad in isolation, in a small flat with somebody who does not stop screaming at me for more than about 20 minutes a day, of course I'm going mad. Who would not under these circumstances?

And I got really angry that I kept being told that I had depression and that I had poor mental health because I don't think I had poor mental health at all, and both of those babies survived that experience, so I must have had my impulses under pretty good control. It was just that it was an intolerable situation. And when I looked around at friends who were being similarly diagnosed under similar circumstances, I thought, if you took any population of well qualified, generally respected people ... I mean, most of us had PhDs, we were young lawyers, we were young doctors, we'd been going places professionally and getting a lot of fulfillment from that. We'd always been out of the house a lot, we'd never been very interested in what the insides of our houses looked like. We'd been young and active and having interesting lives, and we'd been healthy. And childbirth is pretty outrageous the first time, you don't quite realise what it's going to be like, and then we were shut in these little domestic spaces with very little human contact, no sleep, considerable pain, poor access to food, of course we went a bit mad, who on earth wouldn't? I didn't like being told that somehow my feminine fragility had overwhelmed my intellect and I was now a delicate little flower because I felt pretty tough.

Ray Moynihan: But you felt as if healthcare, medicine, whatever we want to call it, doctors were, or the culture perhaps, was pathologising what was in fact a healthy reaction to an incredibly difficult experience.

Sarah Moss: Yes.

Ray Moynihan: I mean, do you think that that is an isolated example? Or do you think that there's something deeper going on in the culture and in medicine, contemporary medicine, about pathologising ordinary life?

Sarah Moss: I think that when you're on the frontline it's much easier to respond to individual cases with care and empathy, if you treat them as individual cases. I think once you start recognizing the structural problems, then you open up the question of structural solutions, which are really, really hard. I mean, to some extent I get this from the other side as a university lecturer. I have a lot of personal tutees, and we know that mental illness is endemic in this population, in this generation, about 40% of our students are diagnosed with some kind of mental illness. It's much easier for me to be kind to my students individually, and to direct them individually towards student support and counselling, and to negotiate individual deadlines for them, than it is for me to try to address the structural problems of their generation, which are to do with politics and economics and employment and the property markets and the way the education system works, but I can't really control any of those things apart from a bit of voting and the odd bit of letter writing. I can't even influence them very much. 

So I don't think that overdiagnosis or pathologising actually quite sane reactions to insane situations is necessarily morally wrong, it may just be individuals responding with empathy and care to other individuals. That's the level on which it's possible to act, whereas the larger levels seem almost intractable. 

Ray Moynihan: Wow. That's very, very helpful, and rather depressing... 

Sarah Moss: Well, I was just ... I mean, the GP who diagnosed me with postnatal depression when my kids were little was absolutely lovely, and she was a really, really helpful presence in my life in those years, and she was responding to me as a good doctor, as a good and caring human who was able to direct me towards resources where there were more good and caring humans who helped. What she wasn't able to do was change a situation that shuts young mothers in houses on their own with no access to extended family or anybody else who could help, places all of the burden for housework and cooking on those young women, makes them feel it's their fault when their babies don't sleep, or don't feed very well. She couldn't do anything about any of that, but she could get individual help for me as an individual person, and she did that. So I don't think it's about bad medicine or bad practitioners, I think it's just about solving things on the level that we experience them.

Ray Moynihan: Let's talk a little bit, if we can, about family relationships. You've raised the situation of the young parents with the young children. It seems that this is a theme that recurs in your work, probably in a huge amount of fiction generally, but there's also a sense of what's said and what's unsaid in your novels. I love The Tidal Zone particularly, the main male character, he seems to ... You often put words into his mouth that he wishes he has said but doesn't say. 

Sarah Moss: Yeah or he's glad he didn't say. 

Ray Moynihan: That's right, and I think we've all experience that, and again an example of the humor there, but that father character in The Tidal Zone, he seems to be an unusual person. He runs a huge amount of the domestic work, cooks, cleans, gets the kids to school, while the mother, as we've talked about before, is a hardworking GP. I mean, I'm really tempted to ask, do you know such a man? Do such men exist who have -

Sarah Moss: Yeah, I'm married to one.

Ray Moynihan: Well, we had the editor of the BMJ on here some time ago, Fiona Godlee, and I think she's similarly married to one as well. I mean, there are men around like that? I mean, do you see, as feminism continues to sort of forge ahead, that more men will be engaged in the domestic life like that?

Sarah Moss: I don't know if it's feminism so much as economics. I mean, I am of the first generation where more women went to university and more women came out with better degrees than the men of our age, and I see that continuing to happen with my own students. I think, I mean, goodness knows, it's slow and we've still got a pay gap 40 years after the equal pay act, and this applies to a very particular group of high achieving privileged women, but I would hope that as more women enter the workplace and crucially survive maternity in the workplace, which is still a major stumbling block, that frees more men to be less driven and ambitious. It allows for other kinds of masculinity as well as allowing for other kids of femininity. And yes, I think I do see that happening among my contemporaries. Certainly, for most of my friends there really was genuine equality up to the point where babies were born, and some couples have been able to reconstruct that after the children start school. 

It's also interesting, I think men's domestic labor is often invisible. If you read articles, or sometimes watch TV, listen to radio programs about fatherhood, there's still an idea that the dad at home is some kind of buffoon who doesn't know how to plait people's hair, and can't really get things right, and makes a mess of things, and needs the wife to come home and sort it all out. And that's so much not my experience of my colleagues and my friends. There are plenty of men who are perfectly competently making bread, cleaning things, keeping an eye on when the kids need to go to the dentist, but you don't really see that work in our culture, and I think that's partly because it's still perhaps seen as slightly shameful that a man who can bake fairy cakes can't be a real man, as Adam observes.

Ray Moynihan: While we're on family dynamics, I was particularly very moved, and I'm sure many, many people will be as well, by the depiction of the mother-daughter relationships in your novel Bodies of Light. You talked a little bit about this earlier, but there's this terrible paradox, this almost crippling paradox, where the mother figure wanted the daughter to succeed and be independent and become a doctor in a man's world, but somehow the mother's expectations were almost impossible and her support for her daughter seemed to come at the cost of her daughter's capacity to be fully human. It sort of rang true. It seemed to be a dynamic that was actually very familiar to many contemporary parent-child relationships. Is it something you deliberately set out to describe?

Sarah Moss: Yes. I was interested in the cost of ambition, the cost of achievement, and what price has to be paid for the kind of success Ally has. I mean, if you think about the way I was describing the training of that first generation of female doctors, the level of toughness and almost dysfunctional resilience, the ability to force yourself through anything, and to keep going no matter what, is never lightly won. I suppose, I mean, particularly now in an era when, at least in the UK, there's a lot of emphasis on teaching children resilience, which is a response to this idea that the millennials are the snowflake generation. I have no time for any of this. Where's the line between teaching resilience and brutalising? And what price are you willing to pay for your children to be successful? 

Again, I think, to some extent, this is a luxury position, but some of us are willing to say, "Actually, I don't think my kids future success is my problem. My responsibility is that they should be good citizens and they should be happy, and what they do with that is really up to them." That's easy to say from a position of security. But what do you have to do to a child to guarantee their success in later life? And is it worth it? And if it's part of some larger project for Ally and her mother? It's her mother's idea that she should go into medicine, it's her mother's feminism kind of forcing the way in front of her. Clearly we do want women in medicine. We do want female pioneers in the professions. We do want the world to change, that's fundamentally it. We want the world to be better, we want our kids to make the world a better place, but what is the individual cost of that move towards a better world? And is it worth paying? I'm just asking questions. 

Ray Moynihan: Another one of Sarah Moss's questions... (laughs) 

Sarah Moss: It's great being a novelist.

> Thoughts on contemporary society vs nostalgia  |  Fiction recommendations  [24 mins 42]

Ray Moynihan: There's a deep appreciation of the work of working people through, I think, almost all of your novels - cooks, cleaners, people who make clothes, people who build roads, you know? Your characters will look at a road and they will just immediately think about all the people who made it and sort of honour them or celebrate that. Where did that arise from?

Sarah Moss: That's probably just me being kind of lefty from very early on. My grandparents on one side were the stereotypical kind of working class Yorkshire pull themselves up their bootstraps, and actually it was World War Two that brought them social mobility. My grandfather was small and had rickets because he'd been malnourished growing up very poor in Leeds in the early years of the 20th century. He certainly knew where things came from, and he took great pleasure in prosperity in later life, but he always, always knew where things had come from and what they'd cost somebody to make. I like ... And I mean, I do a lot of my own making. I like making clothes, and I do most of our cooking from scratch, so I do have a sense of where things come from.

Ray Moynihan: In recent years, many of us feel many reasons for despair. The short list, of course, is Trump and Brexit. For me, and I think others too, the rise of Silicon Valley's control, and that kind of constant surveillance that seems to be entering our lives, and we seem to be embracing so enthusiastically, but I think you've said, "I would like to find intelligent reasons for hope, and to remain progressive." How is that aspiration going?

Sarah Moss: It's pretty difficult, isn't it? I keep ... In retrospect, it looks as if the '90s was really the high point, doesn't it? But the '90s was also when I was a teenager and a very young adult, and I don't want to spend the rest of my life being nostalgic. I've absolutely no patience for those a generation older than me who spend their lives wishing that they were back in the '60s or the '80s or whenever it is, so I am not going to do that. It's not easy at the moment, particularly in Britain, particularly as we watch Brexit land on us from a great height, to believe that things are going to get better, but I think you have to keep trying. 

Ray Moynihan: I can't let you go without asking you for some recommendations for other writers you love, whether writers about health or medicine, or anything really. I'm sure you've got a very long list, but can you just share for free some tips of writers you love.

Sarah Moss: Well, I've been listening to your podcasts, so I knew this one was coming up and I thought about the kinds of things I've been reading recently that have a kind of medical or scientific bent because, as you can imagine, not everything I read does. And I came up with, it's a novel by somebody called Lina Meruane called Seeing Red, which is a first person account of going blind as a complication of diabetes in a young writer, a young woman, and I like it because she's not heroic about it, she's not suffering nobly and angelically, she's writing very angrily and kind of messily about intelligent suffering.

The other one which people may already know is Amy Liptrot's The Outrun, which is a memoir of recovering from alcoholism on the Orkney Isles. And again, I thought as a book that's interested in health and healthcare and recovery, but also in very unconventional ways of addressing illness, it's beautifully written and it's lovely because it's set in Orkney, and she writes very well about birds and landscape. 

Ray Moynihan: Sarah Moss, so much more to talk about, but I think we're probably out of time, so thank you so much for speaking to us.

Sarah Moss: Thank you.

Ray Moynihan: That was a conversation with British novelist Sarah Moss. Special thanks to the BMJ, the folks at Raw FM in Warwick, producer Shauna Hurley, editor Jans Muths and Cochrane Australia, the funder of The Recommended Dose with me, Ray Moynihan. If you like our podcasts, please recommend them to others.