Speculative Public Health in The Physicians of Vilnoc

The word wellbeing might be familiar to many of us as a shibboleth of oppressors and lackeys. We exploit you, we subjugate you, we destroy the ecological basis of life, and we care deeply for your wellbeing: here's an app. (The Out of Office responds: "Thanks for getting in touch. Have the courage to take your boots off our necks, and we'll take the power we need to care for our wellbeing.")

But there is a little more to wellbeing. It is a mixed and contested concept, with roots in moral philosophy, welfare economics, positive psychology, and environmental sustainability. In other words, it’s grounded in debates around the nature of the good life; in the recognition that traditional economic concepts such as utility, and indicators such as Gross Domestic Product (GDP), fail to capture the complexity of freedom and flourishing; in the recognition that health means much more than merely the absence of pathology; and in a holistic concern for a complex, interconnected, more-than-human world. 

Speculative fiction should have things to say about wellbeing. The democratization of wellbeing, its transformation into something more participatory and responsive to the lived experience of health interventions, must therefore be a central concern for utopian and anti-utopian thinking. Speculative fiction should have things to say about public health policy, about health outcomes and health inequalities, about the relationship of health and care . . . What it might wish to say, of course, could mean rejecting these terms and their embedded perspectives altogether. It could mean devising an alternative language.

Has speculative fiction had things to say? Or has speculative fiction struggled to imagine wellbeing policy — or any holistic stance on the myriad factors that inform the health, happiness and flourishing of populations — except where the interested party is some sinister elite, perhaps a paternalistic and unaccountable dystopian government, or a clandestine sect of eugenicists like the Bene Gesserit of Frank Herbert’s Dune? 

Some counterexamples come from a perhaps unexpected direction: epic fantasy. 

Works such as Anne McCaffrey’s Moreta: Dragonlady of Pern (1983) and Tamora Pierce’s Briar’s Book (1999) explore themes such as plagues, quarantine, sanitation, mass vaccination, the influence of socio-economic inequality on health outcomes, and the perils of improperly regulated scientific (magical) research. Lengthy sieges in works like Mary Gentle’s Ash: A Secret History (2000), Umberto Eco’s Baudilino (2002), or K.J. Parker’s Sixteen Ways to Defend a Walled City (2019) dramatise the protection and management of imperilled populations. Magic in works by Robin Hobb, N.K. Jemisin, Ursula K. Le Guin, Vonda N. McIntyre, Brandon Sanderson, and others fantastically reimagine human health and healing within a broader ecological framework and — insofar as such magic systems are concerned with debts, prices, side-effects, balance, resource management, stocks and flows, contracts and the like — within an economic framework too. 

Healing magic is a richly intriguing seam. Dungeons & Dragons and tabletop roleplaying games generally probably have a lot to answer for here, with the frequent emphasis on healthcare as merely the efficient management of a meagre resource pool, and the tendency to elide the experiential dimension of health and wellbeing and focus on health as the capacity to fulfil functions within a relatively fixed division of paramilitary labor. There are plenty of exceptions. A massive critical cultural history of the Hit Point is probably long overdue. 

Lois McMaster Bujold’s The Physicians of Vilnoc (2020), one richly intriguing specimen. The sorcerer Penric is a medical detective posed with the epidemiological puzzle of a new plague, centred on a military outpost. The social dimension of public health is prominent, as Penric proactively manages the risks of rumours, superstition, and panic. 

Many aspects of the tale reinforce a rather conservative and hierarchical health ideology. We are invited to take pleasure in Penric’s competence, experience, and specialist expertise, as he works himself to the bone on behalf of his patients — sick people who sometimes don’t know what’s good for them, and must be slightly misled about the investigations and treatments they are receiving. To some extent, perhaps, the projection of the professionalization of medicine into an early modern fantasy world (the World of Five Gods) may exaggerate the naturalness or inevitability of the dominant paradigm of medical power, and foreclose the possibility of reterritorializing and mutualizing medical knowledge.

The divine order of this universe is solidly anthropocentric too, with Penric’s ‘uphill’ healing magic performed on human patients counterbalanced by ‘downhill’ magical processes that result in the slaughter of fleas, rats, chickens, and the odd pig. 

The nearby community of incarcerated migrants are also soon afflicted but they are, conveniently, so resistive to Penric’s attentions that he never really has to choose whom he cares for. In fact, although Bujold keeps the theme of differential access to scarce healthcare resources bubbling in the background, no ‘Cold Equations’ style hard dilemma ever comes forcefully to the fore. You get the impression that Penric may be making such choices often, but you are not troubled with the details (leave it to the experts). I think I’d venture that nothing Penric or his assistants do is ever really framed as morally questionable. 

On the other hand, even if the quasi-medieval Physicians of Vilnoc does not thematise democracy in any straightforward way, perhaps it has another way of gesturing toward the entanglement of wellbeing and democracy. That is via the fantastical entanglement of entities. First, in a relatively mundane sense, learned Penric is endlessly learning and teaching. And, as Una McCormack points out, “scientific method has to be supported by information gained by divine revelation and folk knowledge.”¹ In this respect, the tale does gesture toward the construction and reconstruction of medical power, and gesture toward the possibility of reconstructing it in far more democratic and participatory configurations.

More fantastically, Penric himself is something of an assemblage protagonist: the character is really Penric and Desdemona, the demon with which he is blended, as well as imprints of a long lineage of Desmemona’s previous ‘riders,’ including nonhuman entities. How large is the universe of morally meaningful beings, and how are we entangled with one another? In this sense, the novella also gestures toward the interconnection of human wellbeing with more-than-human wellbeing, and indeed the role that 'the human' as an immanent concept in history has played in the definition and distribution of the good life. However we define wellbeing, speculative fiction can propose entities with altogether different capabilities, including perhaps capabilities for wellbeing. 

1. "The Cure at Vilnoc: scientific method, revelation, and folk wisdom in ‘The Physicians of Vilnoc.’" In Short But Concentrated: An essay symposium on the works of Lois McMaster Bujold, eds Una McCormack and Regina Yung Lee.