Medicine and science fiction: review

My original essay on the subject

The Fourth Horseman

There is a continuum from medical thrillers to science fiction, with the distinction that thrillers generally salvage civilization as we know it, whereas SF writers take delight in portraying civilization’s collapse. Thrillers end before the midnight hour of irretrievable change, no matter how ambiguously (as in Ken McClure’s Requiem ), whereas science fiction takes us through the hours after midnight. In a thriller, an outbreak of disease will claim a handful of victims before being contained. In SF, it is equally likely to leave but a handful of survivors.

… one day in midsummer when some semblance of communications networks were being pieced back together again… someone speculated in official tones that on that morning something in the order of seventeen million pairs of American eyes had greeted the dawn. Nobody really believed the figure; on the very face of it, it was really pretty unbelievable. And everybody was probably right, too.

It probably wasn’t the right figure.

–Alan E. Nourse. The Fourth Horseman

Great Plagues are a stable of science fiction as a means of demolishing civilization and redrawing the human map, without all that messy radioactivity (bodies decay much faster than Strontium-90). A coarse distinction can be made between novels which dissect the anatomy of the disaster and those which focus on the aftermath, the classic after-the-plague novel being George R. Stewart’s Earth Abides. Novels set during the plague itself tend to concentrate upon the human and medical response: The Time of the Fourth Horseman (Chelsea Quinn Yabro), The Fourth Horseman (Alan E. Nourse), and Disposable People (Marshall Goldburg MD and Kenneth Kay). In the main, such small victories as are achieved come through individual effort. The medical establishment and its representatives are shown to be at best ineffective, at worst venal. The epidemics loose in The Time of the Fourth Horseman are a result of deliberate introductions coupled with adulteration of medicines in a deliberate, catastrophic, strategy of population control, and the plague of The Fourth Horseman might have been contained but for a drug company’s withholding a potential cure because the drug is too simple, too readily made, to be profitable.

As to the diseases that end (or threaten to end) the world, in The Fourth Horseman the plague is truly the Plague, Yersinia Pestis , mutated to a form both highly transmissible and antibiotic resistant. This time it is not London that burns, but Savannah, the Pearl of the South. Yersina appears again in Connie Willis’ Doomsday Book, in which a time-travelling graduate history student is stranded in Plague-ridden fourteen century England when an epidemic influenza paralyses her home base in twenty-first century Oxford. Meningitis is one of several killers in The Time of the Fourth Horseman, while measles conquers not only H.G. Wells’ Martian invaders but the civilizations of Earth in Earth Abides. Infectious insanity appears in Edmund Cooper’s All Fool’s Day. Extraterrestrial plagues feature in The Andromeda Strain and Octavia Butler’s Clay’s Ark. In the latter, the plague does not kill its victims but mutates them and their offspring, and a number of Butler’s other books are set against a background of ongoing war between Clayarks and the normal humans. The Changeling Plague (Syne Mitchell) originates from a gene therapy cure engineered by a rogue physician for a desperate (and very rich) young man. What brings pitiful death to many proves to bring liberation and transcendence to others. In James Tiptree, Jr’s “The Screwfly Solution”, the human race faces extinction from an alien-induced epidemic of homocidal violence against women.

Moving further into the realm of the fabulous, vampirism is usually portrayed as an infection suffered by a few, but the hero of Richard Mathewson’s I Am Legend finds himself the last living man in a world of vampires. In literature of a hundred years ago, vampirism was sometimes used as a metaphor for syphillis, with its connotations of blood, madness and eroticism. Today it has become a metaphor for AIDS, the newest plague. Dan Simmons’ Children of the Night, brings the two together in a novel in which vampire blood proves to carry the cure for AIDS. Other AIDS novels are F.M. Busby The Breeds of Man, Thomas M. Disch The M.D.: A Horror Story, in which an ambitious young physician makes a truly Faustian bargain, and Norman Spinrad “Journal of the Plague Years”.

One of the ‘revenge effects’ described by Edward Tenner in his book Why Things Bite Back concerns the exchange of acute medical conditions for chronic. Even AIDS has, with continued advances in treatment, become a long-term disease. Chronic affliction has superceded catastrophe in novels such as Rita Donovan’s The Plague Saint, in which a monolithic Church uses both the plague and the far from immaculate heroine to its own ends, and The Handmaid’s Tale, where infertility and fundamentalism have engendered a dystopia.

Doctors often appear in postholocaust settings such Pat Frank’s Alas Babylon and Joan Slonczoski’s The Wall Around Eden as heroic figures poignantly aware of the contrast between their stature as essential citizens in their community and their owninadequacy. Wall around Eden‘s Dr. Marguerite Chase confesses to administering euthanasia to radiation deformed infants whose care would pose an unsupportable burden to her small commnity.

Bad Medicine

Since doctors as individuals can literally hold the power of life and death over people, and the medical profession as a collective can dictate the shape of society – whether alone or in symbiosis with other powerful elements – novels of individual villainy and collective tyranny abound. I would venture to say that medical totalitarianism (especially eugenic) is to the late twentieth century what political totalitarianism was to its middle decades. Themes which recur in science fiction include, control of access to treatment by the medical profession or government, control of reproduction – both who shall reproduce and how they will reproduce – and deliberate spread of disease – natural or man-made – usually as a means of population control.

Caduceus Wild (Ward Moore, Robert Bradford) is a full-blown medical dystopia, in which the population of the United States is (post plague) divided into Doctors and Patients. The novel follows the efforts of a family of dissidents to escape to liberal England through the heartland of the Medarchy. In Alan E. Nourse’s Bladerunner access to medical care is dependent upon acceptance of eugenic dictates including sterilization, a situation which is tenable only because black-market doctors are prepared to care for those who do not comply. An epidemic causes the collapse of the modus vivendi between legal and illegal care. State regulation of sexuality is a staple in classic dystopias, as in Nineteen Eighty Four (George Orwell), Brave New World (Aldous Huxley), We (Yevgeny Zamyatin), Anthem (Ayn Rand). The influence both of feminism and the increasing acceptance of reproductive technology have led to a further examination of the implications of increasing medical control over reproduction. Benefits (Zoe Fairbairns) traces the insiduous progress from the initial programme of benefits for mothers through the introduction of measures to deter the genetically flawed from having children, and finally to the universal contraceptive in the water supply. A contraceptive which, when combined with its antidote (as given approved mothers), proves a potent mutagen. The medically trained councilwomen of Women’s Country are the ‘damned few’ responsible for the eugenics program which they hope will ultimately breed out of mankind the urge to towards warfare and domination (The Gate to Women’s Country Sherri S. Tepper). Deliberate introduction of disease as a means of population control appears in The Time of the Fourth Horseman, The Sea and Summer (George Turner, also titled The Drowning Towers), and the medical thriller White Eye (Blanche D’Alpuget) where the disease is not intended to kill but to sterilize its victims. In “The Last Flight of Doctor Ain” by James Tiptree Jr., the eponymous protagonist travels the length and breadth of the planet, spreading a mutant virus which he hopes will unburden the suffering Earth of humanity.

The use of psychiatry for social control provided a rich vein for writers, particularly in the middle decades of the century. In “The Diary of the Rose” (Ursula Le Guin), a therapist comes inexorably to the discovery that the madman whose mind she is exploring is a political prisoner and his illness is dissent. More recently, torture and imprisonment has cropped up as a theme in several novels (SL Veihl’s Endurance, Ann Tonsor Zeddies Steel Helix, and the Judiciary novels of Susan R. Matthews). In the first two novels, the physician is victimized and limited in his or her actions, but not stripped of moral authority. An Exchange of Hostages (Matthews) and its sequels provide something a little bit different in the person of the honourable, tormented Andrej Koscuisko, recruited against his will to serve as a “Ship’s Inquisitor” (i.e., legal torturer), but who discovers that his appetite for others’ pain runs as deep as his revulsion for his profession. In The Devil and Deep Space he at last has the insight that allows him to make his break with the Judiciary. On the planet Irustan, (The Terrorists of Irustan Louise Marley) where women are veiled and confined, illness is despised and healing a female profession, a medicant’s vows crumble under the abuses she witnesses; healer becomes killer.

Grand Rounds in the year 2400

The best known series about the ordinary working life of a doctor of the future are the Sector General novels of James White, which follow Dr. Conway and his human and alien colleagues of the multi-species, multi-environment space station/hospital Sector General. Most recent in the series are The Galactic Gourmet, in which the galaxy’s greatest chef undertakes the galaxy’s greatest gastronomic challenge – to make hospital food palatable – and sets about it with such utter singlemindedness as to cause havoc, Final Diagnosis, in which a xenophobic patient arrives suffering from a mysterious illness, and Mind Changer.

In contrast to the ‘tertiary care centre’ that is Sector General, Calhoun in The Med Series (Murray Leinster) is the public health inspector, travelling from colony to colony, alone but for Murgatroyd, an ape-like creatures who acts as a living toxicology and immunology laboratory. Alan E. Nourse’s Star Surgeon portrays life for the interns of the future, as new graduate Dal Timgar and his two colleagues set out aboard the General Practice Patrol Ship Lancet. Surgeon Dr. Cherijo Grey Veil, herself the product of illegal genetic engineering, leaves a sheltered life on isolationist Earth for an understaffed clinic on a multispecies colony and finds friendship, love, strange physiologies and plague, in S.L. Viehl’s Stardoc. In the sequels, Cherijo’s life goes from bad to worse as she is hunted by her progenitor, enslaved by the Hss’kt, enthralled by the enigmatic telepath, Duncan Reever, and re-captured by her progenitor/creator.

Diane Duane’s first career was as a psychiatric nurse, and in her Star Trek novels she cuts the healers in on the action, sending Dr. McCoy behind enemy lines to contact a deep penetration agent on Romulus (The Romulan Way) and putting him in command of the Enterprise in Doctor’s Orders. In Dark Mirror, the crew of the Enterprise D encounter their mirror-selves (classic Trek “Mirror, Mirror”) and empathic Counsellor Deanna Troi discovers that when she is bad she is horrid. Barbara Hambly gives the often caricatured Christine Chapel depth and importance in Ghost Walker and Crossroads. The latter is unique for postulating a distinctly dark future for the Federation. But my favourite medical person in Star Trek novels has to be Dr. Evan Wilson in Janet Kagan’s Uhura’s Song, who pilots a skiff called the Dr. James Barry, and like that gentleman is other than she seems.

A different kind of medicine is practiced by the itinerant healer Snake, from Vonda MacIntyre’s Dreamsnake (Vonda MacIntyre) who uses the venom from her three snakes to ease pain and, if need be, to administer euthanasia. Flesh and Silver (Stephen L. Burns) is the story of one of the surviving Bergmann Surgeons, a bilateral amputee who has acquired the ability to perform psychokinetic surgery, but who has paid the price in alienation from his lover, his patients and from his colleagues. When the male-only planet Athos (Ethan of Athos, Lois McMaster Bujold) is faced with a population crisis, reproduction specialist Ethan Urquart finds himself shanghaid into venturing into the wicked, wide galaxy, where he encounters women and other aliens, not to mention telepaths, mercenaries and ruthless practitioners of of the arts of espionage, assassination and infection control.

The cure for cancer and the long dark teatime of the soul

The flawed cure is a recurrent theme in medical thrillers and science fiction. In thrillers the race is to prevent the application of the cure, usually cast as a contest between integrity and greed, as in Kate Wilhelm’s The Clewiston Test. In science fiction again the hour is set long after midnight, as in Edward Llewellyn’s Prelude to Chaos, The Bright Companion, and The Douglas Convolution in which a widely used cancer preventative is revealed to cause female sterility only after an entire affected generation has reached womanhood. The Changeling Plague (Syne Mitchell) is a worst-nightmare scenario where a gene therapy vector proves not only infectious but mutagenic.

The ultimate prize for medicine is, of course, the abolition of death itself, although science fiction’s take on immortality tends to be cautionary. Douglas Adams ( The Hitchhiker’s Guide to the Galaxy) observes that many long for immortality who do not know what to do with themselves on a rainy Sunday afternoon, “the long dark teatime of the soul” (Anyone who grew up in the UK twenty to thirty years ago knows exactly what he means.) As a cure for ennui, one of his immortals has undertaken – with the aid of a time travel machine – to insult, in person, everyone who has ever lived. In Sharon Webb’s Earth Song trilogy (Earthchild, Earth Song, and Ram Song) an immortality process which only takes effect if given before puberty has the immediate effect of setting parents against children – and the long term effect of destroying human creativity, which seems only to flourish in the shadow of death. And in a story by Brian Stapleford (“The Magic Bullet”, collected in Sexual Chemistry, Sardonic Tales of the Genetic Revolution), immortality sets men against women, including male mentor against female protege, since immortalization is dependent on a supply of ova. In Kate Wilhelm’s Welcome, Chaos, immortality is dispensed in the form of a plague (with substantial mortality) – the only way of keeping it from being exploited or repressed.

A substantial increase in lifespan – and the social disruption that results – is the reason for The Trouble with Lichen (John Wyndham), in which biochemist Diana Brackley approaches the problem of securing support for her discovery of an antigerone by marketing it as an exclusive beauty treatment to the wives of the powerful and influential. The settlement of Mars and the relationship between Earth and Mars is affected by the development of a life prolonging treatment in Kim Stanley Robinson’s Mars Trilogy .


  • The Encyclopedia of Science Fiction. Second Edition. John Clute and Peter Nichols – particularly entries for MEDICINE, END OF THE WORLD, IMMORTALITY,GENETIC ENGINEERING
  • UltimateSF guide – World comes to an end
  • UltimateSF guide – Immortality
  • The SF Book of Lists. Maxim Jakobowski and Martin Edwards
  • No Cure for the Future: Disease and Medicine in Science Fiction and Fantasy. Gary Westfahl and George Slusser, eds.
  • Nearly 30 years of voracious and indiscriminate reading!

Asides and addenda

Plague has also been used in a number of feminist novels to redraw the social map by making the plague sex-specific. In the main, these are post-plague novels, the authors more interested in depicting the all-female society that results as in – “When It Changed” and The Female Man (Joanna Russ), Ammonite (Nicola Griffith).

Infertility is another popular theme of science fiction – occurring in (among others) Greybeard (Brian Aldiss), The Twilight of Briarius (Richard Cowper), The Children of Men (P.D. James), Prelude to Chaos (Llewellyn)… it is the rare writer who does not, however, relent by the end, but the solution is seldom medical and often has mystical overtones.

Dr. James Miranda Barry (1799-1865) matriculated at the University of Edinburgh medical school at the age of ten (that was before age restrictions), graduated at age twelve, trained in surgery in London, and, despite a peppery disposition and an unfashionable commitment to preventative medicine, rose through the ranks. Although there was rumour during her lifetime, her true sex was discovered only upon her death.

Medicine and Science Fiction Page (v 1.0) prepared by Alison Sinclair., January – February, 1998. Last amended April 20, 2003.