Chimamanda Ngozi Adichie - Dream Count (Harper Collins, 2025) ****

"Dream Count" refers to the list of potential true lovers than Chia, the lead voice in this novel, has had yet failed to turn into true romantic and eternal deep love. She is a Nigerian author living in the United States, and interacting with her two best Nigerian friends: her cousin Omelogor, and Zikora, both of whom are not really on friendly terms, but get called into Zoom calls by Chia, because it's the period of lockdown in the Covid-19 pandemic. All three are well-to-do and well-educated. Chia is a would-be author, but also making a name as a travel writer. Omelogor prefers to live in Nigeria, and works as a financial consultant, after having been a big shot in one of Nigeria's banks, and Zikora is a corporate lawyer living in DC. All three are concerned and discuss the fate of Chia's maid, Kadiatou, hailing from Guinea and involved in a rape case inspired by the court case between IMF head Dominique Strauss Kahn and a hotel maid in 2011.  The novel mentions the incident, and that the perpetrator was a French high official of an international organisation, but without mentioning his name. 

Apart from the interrogations and upcoming trial for the rape case, there is no real plot in the novel. The four protagonists each tell their personal history and thoughts on love and society from their own personal perspectives. They talk about their countries, their travels, their family, their friends and lovers. It is programmatic in the sense that all types of men appear to have been one-time lovers of the three forty-year olds. The men are described one by one, some at length, some just briefly. Promising new relationships unfortunately all fail because of some short-comings the men have. 

Chimamanda Ngozi Adichie writes extremely well. Her view on society and men through the eyes of the women is harsh, honest, brutal, sensitive, generous and very angry at times. Her feminist agenda is clear, but that should not spoil the fun. The comments and viewpoints of the women are smart, often justified, and made me frequently laugh out loud, yet the deep dark evil of the rape of the maid, the least educated, the most innocent, the most vulnerable gives the book much more depth and seriousness contrasted by the predicament of the three rich narrators who are waiting for mister right. A novel of contrasts, giving an interesting insights in the perspectives of African women living in the United States, but especially one of solidarity among women in world that is far from perfect. 

 

Stefan Larsson - The Patient Priority (McGraw-Hill, 2023) ***½

An excellent book on Value-Based Healthcare written by three consultants of the Boston Consulting Group. Many of the ideas they suggest, I agree with, and they can also be found in my own book "De Stem van de Patiënt" (Lannoo, 2025). As the former co-chair of the European Alliance for Value in Health, I can only support the angle of approach to look at healthcare from an outcomes-based model instead of a service-based model. Originally, healthcare consisted of individual physicians offering care to individual patients, using technology that had been approved by the autorities. Today, healthcare has become much more complex, with many more interventions, stakeholders and integration of care services. All the costs were evaluated by the service provided and the cost of the technology. This is absolutely unsustainable, and other forms of payments are needed: bundled payments, capitation or other approaches that look more at the total picture, more collectively and based on the results obtained. 

They also plead for better integration of care, by type of disease or condition, and based on solid registries. 

"In the past, outcomes measures have traditionally been developed by spe­cialty societies and, therefore, tend to focus on specific interventions or procedures. Sometimes, focusing on a specific procedure makes sense. Cataract surgery is probably the best example, because it is the only treat­ment for patients suffering from cataracts. But in most situations, the ideal health outcomes to track for a given condition should reflect the overall care for a patient's medical condition, in which multiple specialties are usu­ally involved and multiple treatment options are available, so clinicians can assess the relative effectiveness of different types of treatment. Procedure­-based registries have played an important role in improving hip and knee arthroplasty, but they can't really address the broader question about the optimal treatment for the underlying disease of osteoarthritis. Or consider a patient suffering from back pain: for that condition, the relevant out­comes measures should be broad enough to assess the comparative impact of, say, physical therapy versus surgery." (p.56)

This approach should look at the entire patient pathway from prevention to end of treatment. Today, care is really a step-by-step approach, with none of the steps seen as being part of a disease continuum. Obviously the reality is different, and patients also live in a world where they are confronted with other problems that does not always make treatment optimal.  

"An approach to care delivery that integrates both clinical interventions along the entire treatment pathway and nonclinical interventions that encourage prevention and address the social and behavioral determinants of health is not only a more effective way to monitor and treat patients, it also allows for better coordination across multiple stakeholders and gives health systems full visibility of the system costs to make informed trade­offs-for example, investing in preventive care to avoid high treatment costs at later points in the care-delivery value chain." (p. 74)

The Netherlands for instance, had a visionary idea, that we can fully support, based on the following four essential points. Whether this has actually been done, I have not been able to verify. 

1. "To reach a consensus among key stakeholders by 2022 on the out­comes to be measured for conditions representing 50% of the total disease burden, both by adapting international standards for use in the Netherlands and by developing new metrics
2. To support shared decision-making on treatment choices between providers and patients, by making health information more under­standable for patients, and· by equipping health professionals with the necessary skills and information to have meaningful conversa­tions about treatment choices with their patients
3. To promote the outcome-based reorganization of care delivery and reimbursement through the sharing of best practices, the devel­opment of more integrated care chains, and the encouragement of more outcome-based contracts between insurers and providers
4. To facilitate better access to relevant and up-to-date outcome information, through the development of a state-of-the-art health informatics infrastructure, with the goal of making it easy for patients to report data, ensuring that data is well-organized and scalable, promoting access for all relevant parties for the purposes of benchmarking and research, and maintaining privacy and security" (p. 216)

Even if I can agree on most of what the authors write, they still cannot capture the patient perspective on things. Their approach is one of change management for the healthcare system, and of course they are self-interested consultants hoping to get clients among governments to help reorganise their healthcare towards better outcomes and more financially sustainable, yet they somehow miss the essence: patients and the patient community by disease are the real decision-makers when it comes to determining key performance indicators for outcomes, and to assess whether the expected results have been achieved. Without a solid and formal integration of the voice of patients in healthcare, it will remain a structure with one blind spot, and a big one: what patients need. Without systematic and robust feedback from the end users, no system can properly function. 

Because of this lack of patient perspective, there is also barely any mention of patient advocacy or patient organisations in their analysis, which is disturbing to say the least. As representatives of the 'lived experience' we can advocate for better adherence, better alignment with the life goals of individuals, helping to capture patient satisfaction data, etc, etc. 

That is what we are advocating for. That is where the low-hanging fruit is to be found. 

W.G. Sebald - The Rings Of Saturn (Vintage, 2020) ****½

German author W.G. Sebald was also a professor of literature, and was appointed at the University of East Anglia in Norwich UK. Like his other novels "Austerlitz"(2001), "A Place In the Country" (1998), and "The Emigrants" (1992), Sebald's writing fits in a category of its own, a kind of literary non-fiction. In "The Rings Of Saturn", originally published in German in 1995, he describes a long walk along the British east coast, starting is Lowestoft, walking south to Orford, then travelling back inland to the north-west. 

Like in his other books, the travels are just a pretext to tell stories and reflections on historical events that took place in relation to the places he visits. As you can see from the 'content' pages below, he can talk about almost anything yet always with a great passion for the subject, a kind of naive enthusiasm while keeping a cynical distance at the same time. He talks about Chateaubriand, Sir Thomas Browne, Swinburne, fishing fleets, a matchstick model of the Temple of Jerusalem, recession-hit seaside towns, wooded hills, Joseph Conrad, Rembrandt's "Anatomy Lesson," the natural history of the herring, the massive bombings of WWII, the dowager empress Tzu Hsi, and the silk industry in Norwich. His deep interest lies always in the past, in the 19th and early 20th century, and his mood is one of melancholy as if he had hoped to have witnessed those things first hand. His knowledge on the subjects he covers is wide, and he must often also acknowledge that he does not know how he knows this. He can say, "I could not identify where I read this information".

He marvels at the world, at people, at inventions, at nature and animals, and whatever the subject, his writing is entertaining, beautiful and very literary. And always, behind the light-footed tone, behind the apparent sometimes insignificant trivia, behind the text, there is a sense of loss, of doom, of darkness. 

On Sir Thomas Browne: 

"Browne's writing can be held back by the force of gravitation, but when he does succeed in rising higher and higher through the circles of his spiralling prose, borne aloft like a glider on warm currents of air, even today the reader is overcome by a sense of levitation. The greater the distance, the clearer the view: one sees the tiniest of details with the utmost clarity. It is as if one were looking through a reversed opera glass and through a microscope at the same time. And yet, says Browne, all knowl­edge is enveloped in darkness. "What we perceive are no more than isolated lights in the abyss of ignorance, in the shadow-filled edifice of the world". (p. 19)

On the herring:  

"An idiosyncrasy peculiar to the herring is that, when dead, it begins to glow; this property, which resembles phosphorescence and is yet altogether different, peaks a few days after death and then ebbs away as the fish decays. For a long time no one could account for this glowing of the lifeless herring, and indeed I believe that it still remains unex­plained. Around 1870, when projects for the total illumination of our cities were everywhere afoot, two English scientists with the apt names of Herrington and Lightbown investigated the unusual phenomenon in the hope that the luminous substance exuded by dead herrings would lead to a formula for an organic source of light that had the capacity to regenerate itself. The failure of this eccentric undertaking, as I read some time ago in a history of artificial light, constituted no more than a negligible setback in the relentless conquest of darkness." (p. 58-59)

Yet his trivia are also fun. He knows how to take the reader by the hand, and make him/her look at things differently. He also tells for instance the story of his grandmather who kept goldfish, and who washed her each of them with soap every day, and then put them on the windowsill to let them enjoy the air a little bit, before putting them back in their aquarium. Or this description is typical of how he builds up his descriptions to a climax. 

"No details of the end of the three-master have come down to us. There were eye­witnesses who claimed to have seen the commander of the English fleet, the Earl of Sandwich, who weighed almost twenty-four stone, gesticulating on the afterdeck as the flames encircled him. All we know for certain is that his bloated body was washed up on the beach near Harwich a few weeks later. The seams of his uniform had burst asunder, the buttonholes were torn open, yet the Order of the Garter still gleamed in undiminished splendour" (p. 77)

I can also appreciate his view on Belgium, yet not entirely either. 

"And indeed, to this day one sees in Belgium a distinctive ugliness, dating from the time when the Congo colony was exploited without restraint and manifested in the macabre atmosphere of certain salons and the strikingly stunted growth of the popu­lation, such as one rarely comes across elsewhere." (p. 122)

Deep down, something is indeed terribly wrong with our world, and he sees things evolving for the worst, affecting the author too. 

"It is as if everything was somehow hollowed out. Everything is on the point of decline, and only the weeds flourish: bindweed strangles the shrubs, the yellow roots of nettles creep onward in the soil, burdock stands a whole head taller than oneself, brown rot and greenfly are everywhere, and even the sheets of paper on which one endeavours to put together a few words and sentences seem covered in mildew. For days and weeks on end one racks one's brains to no avail, and, if asked, one could not say whether one goes on writing purely out of habit, or a craving for admiration, or because one knows not how to do anything other, or out of sheer wonderment, despair or outrage, any more than one could say whether writing renders one more perceptive or more insane" (p. 182)

Brilliant.