The book opens with Shep Knacker packing his bags for his long-dreamed of “Afterlife”—his word for retirement—in Pemba, an island off the coast of Tanzania. He plans to take his wife, Glynis, and his high school aged son, Zach. This plan is not unexpected because Shep and Glynis have made many “research” trips during their 26-year marriage to find the right place (though never to Pemba). But, there were always reasons not to act on their research. An intervention was needed. Glynis is not home while he is packing because she is at some “appointment.” When she gets home, Shep informs her of his plans for the three of them to leave for Pemba, and he further informs Glynis that he’s going whether she comes or not. In response, she informs him that she has cancer—a bad one (mesothelioma); he unpacks, so much for that.

What unfurls from there is more complicated than just the challenges Glynis’s disease produces, though these are monumental challenges. Other people, too, are in need of Shep’s attention. His father’s decrepitude is advancing, his sister is on the brink of homelessness, and his teenage son is detaching from him and life in general. Shep eventually loses his job as an employee at the handyman company he once owned (“Knack of All Trades”) then sold to fund his Afterlife. There’s more. 

Shep's best friend, Jackson, who also worked with him at Knack of All Trades has two girls, and one of them has familial dysautonomia. This progressive genetic disease of the nervous system produces a constellation of medical problems that are bizarre, intense, and serious, before it ultimately produces a tragic end. The trauma and tragedy this disease inflicts in this story (and in life) encompass the entire family, in spite of the heroic efforts of Jackson’s wife, Carol. 
The many plot lines in this novel at times proceed independently of one another, and at other times intersect. They concern serious illness experiences and the effects they have on families and also how the American health care system can place burdens on those who need it. Nevertheless, the two families, beaten down by illness, fatigued from encounters with doctors and hospitals, and exasperated from fights with insurance companies, rally enough to make it to Pemba. The trip becomes financially affordable as the result of some narrative gimmickry involving a financial settlement of $800,000 from the company that put asbestos in equipment Glynis had used years before. They would spend the rest of their lives there, longer for some than for others.   


At its core, this novel is about the cost of health care, and in particular about whether money should ever be a factor in health care decisions for patients. The answer this novel gives to that question is, yes.  

The author, Lionel Shriver establishes money as the primary subject of the novel before the first chapter with the epigraph: “Time is money” (quoting Benjamin Franklin). Then, the very first chapter starts as follows:

Shepherd Armstrong Knacker 
Merrill Lynch Account Number 934-23F917
December 01, 2004 - December 31, 2004
Net Portfolio Value: $731,778.56    

As the story moves along, some chapters open in the same format, which shows the depletion in portfolio value over time until it reaches a nadir of $3,492.57 on the January 01, 2006 - January 31, 2006 portfolio statement. It is the depletion of this portfolio that creates opportunities in the plot lines to interject reflections and conversations about whether it makes sense to spend a lot of money for certain health care options.  

The opportunities begin early in the story when Glynis’s primary physician recommends she put herself under the care of a particular oncologist, but warns her, “…you might be levied a higher percentage of co-insurance. And given the stakes…Well, I assume that money is no object.” (p. 50) Shep starts then and there to consider “this quantity now officially of ‘no object’.” Of course it had no value by itself. Money was a means. But to ends not readily dismissed as ‘no object’.” (p. 50) Several subsequent incidents build further on the question about whether money was an object or not before reaching an apogee in the form of a conversation with Glynis’s oncologist, Dr. Goldman, who wants to try an experimental use of a particular drug in a last ditch and very likely futile effort. Goldman tells Shep that the treatment would cost $100,000 and insurance would not pay for it because it’s an experimental use, but “there’s not much to lose.”    
“A hundred grand. There’s ‘not much to lose’? I guess I’m not in your income bracket. Since that strikes me as a whole lot.”
...We’re talking about your wife’s life here...I have to assume that money is a secondary issue at best, if it’s an issue at all.” 
“So, if I say it’s an issue, I’m an animal, right? But even if I fall in line and say, by all means, doctor, do anything you can...because I love my wife and money is no object. Why do you assume I’ve got a hundred grand?”
“...It’s really Mrs. Knacker’s decision, when she wants to call off further treatments...she sounded keen to try it.”
“...I realize she’ll try anything. But it is not my wife’s decision if she’s not the one who’s going to pay for it.” (pp. 378-379) 
In challenging the idea that money can be an object in health care decisions, Shriver offers readers a chance to contemplate the possibility—permissibility—of using health care costs as a basis for decisions at a time when this subject is not commonly debated in the public sphere. 

While the question of whether cost can be a factor in health care decisions is the primary concern in the novel, Shriver also concentrates on the illness experience. She makes vivid some of the physical manifestations of mesothelioma and familial dysautonomia; it’s not for the squeamish, but these experiences are real and are often best rendered in literary fiction as compared to biomedical texts and news media accounts. Shriver also, however, considers illness experiences that are not related to physical aspects. For example, she delves into the inner thoughts Glynis has about who she had become since her diagnosis. 
Before Glynis had become something of a mystery to After Glynis—like the kind of faintly exasperating relative with whom you have little in common and about whom you have opinions to begin with only because you happen to be related by blood. (Were they? Related by blood? Arguably, not anymore. The blood in her veins had been replaced several times. She was no longer related ‘by blood’ to herself.) (p. 309)          

Shriver also builds on the isolating nature of illness that Susan Sontag, Virginia Woolf, and others have described through one metaphor or another. Whereas these writers say that illness is inherently isolating, Shriver suggests that the isolation can result from family and friends abandoning the patient.
Glynis’s cousins, nieces and nephews, neighbors…and most shockingly of all her friends had rung up less and less frequently, speaking more and more briefly. They had all spaced their visits more and more widely, and withstood his wife’s company a steadily shorter period of time. (p. 276)
Through Shep’s reflection on the abandonment Glynis was experiencing, Shriver refers to it as “social attrition,” and in an explicit gesture towards Sontag’s metaphor of illness as the “night-side of life,” she attributes it to people having “never been taught how to behave in relation to a whole side of life—the far side—that had been staring them in the face since they had a face.” (p. 281)

Other experiences Shriver calls attention to include: physicians using patients as objects for their research interests and self aggrandizement; the varying effects a mother’s illness can have on relationships among individual family members; events that can lead to suicide; and the frustrations and inefficiencies of health care insurance that carry their own toxicities.              



Place Published

New York



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