Thanks to NetGalley and to Titan Books for providing me an ARC copy of this novel that I freely chose to review.

I have read a number of glowing reviews of Tremblay’s novels and being a horror fan, I was eager to read one of his books. When I found this one was available for request and read the description, I requested it although wondering if, in the current situation, I’d dare to read it. Then I read a review of it by one of the reviewers of horror I trust and decided to take the plunge. I’m pleased to report it was the right decision.

The description does justice to the plot. This is one of those novels that seem to start with a big “What If” , and we have a clock ticking to ramp up the tension. The fact that the situation has become familiar and requires far less suspension of disbelief than it might have when it was written adds nuance to the story and also increases the chill factor. Yes, the details are different (there is a virus, but it is a variety of the rabies virus rather than a coronavirus, and therefore the illnesses are very different, thankfully), but the background situation and the consequences of the health emergency are eerily similar (lack of resources, lack of PPE, confusion, hospitals overwhelmed, lack of coordination, fake news, conspiracy theories, nay-sayers, heads of governments ignoring scientific advice…). Rather than going large, the author bring the crisis to a personal level, focusing on the story of two women, one British who emigrated and studied Medicine in the US, Ramola, or Rams, and the other, her best friend, Natalie, Nats, married and in the late stages of pregnancy. They shared an apartment while they were students, and although their lives have changed, they’ve kept in touch. Things go wrong very quickly, and Ramola is soon forced to make decisions that place her professional duty in the balance against her friendship. Would you put your duty to society before your friendship or your love for your family? This is a question many of us have probably wondered about, and many have been force to face for real in recent times.

The story turns into a nightmarish road trip where almost everything is against the protagonists. There are infected animals (and people) on their way, roadblocks and rogue patrols wondering the streets, and every time they seem to get a break, a new obstacle or delay makes survival more and more difficult. And, of course, we have the illness itself, which turns humans (and animals) into raging wild beasts.

 I have mentioned some of the themes, and although this is a dystopian story that feels like reality at the moment (unfortunately, reality is looking grimmer than this novel’s scenario), and it does have much in common with zombie stories (no matter how insistent Rams is that the infected are not zombies, and, of course, they are not dead but ill, their behaviour is quite similar), it is also a story about friendship and the families we create. We have not only Ramola and Nathalie, who are like sisters, but also other characters (especially a couple of teenage boys, Luis and Josh, who are like brothers, share a dark secret, and whose story is given space as well). There is no lack of social commentary either:  there is a strong indictment of the lack of training, of PPE, and of resources in general that hospitals and health providers have to contend with, and also support for the usefulness (indeed need) of vaccines and vaccination campaigns. (Tremblay explains at the end that his sister works at a small hospital and she gave him a lot of information.  They make a great team). Although none of it is original, it does work well, and the focus on only a few characters makes it very compelling.

The story is written in the present tense (for the most part), in the third person, although the chapters alternate between the points of view of Natalie and Remola in the three main parts of the novel. There are also a prelude, and interlude, and a postlude, which are told from a seemingly omniscient viewpoint, where the narrator provides a frame and a commentary on the story itself (we are told this is not a fairy tale, it is a song, and we are also given information about the larger scale of things, and even told about the future). My experience with present tense narration has not always been good, but I felt it worked well here, as it makes readers feel as if the story was taking place right now, and as the main narrative develops over a few hours, it does bring home the relativity of time, how two minutes can feel like two hours, or vice versa. The book has some lyrical passages, and it’s particularly strong when reflecting the way our minds can wander even at the most inconvenient moments, and how we all have our own protective mechanisms (telling ourselves stories, taking refuge on events from the past, fairy tales…). The author writes fluidly and he makes good use of the alternating points of view, and of other devices, like Facebook chat pages, the video diary Natalie is keeping for her child… This also provides variety and a bit of a break from the tension of the story.

I’ve read some reviews where people didn’t like the book because they didn’t like the main characters. It is true that because of the way the story is told, if you don’t connect with the two protagonists, I don’t think the story will work. We don’t know everything about the two characters straight away, as much is revealed through the novel, as they think about the past, about shared experiences, and also about the future. For me, the relationship between the two characters felt real. They often knew what the other person was thinking, they cared for each other and it was like reading or witnessing the interaction between two close friends, where not everything needs to be said, and there is a lot of background to the relationship that will not be evident to strangers. Being a doctor, I probably felt closer to Ramola and her difficult situation, but I enjoyed the story and I also got to like Luis and Josh (and some of the minor characters as well).

The ending… Well, if there wasn’t a postlude, the ending would be ambiguous but the postlude makes up for it, and we get a satisfying ending (if not particularly surprising). I confess I’m not a fan of happy endings for horror novels (or films), but this is not standard horror, and despite the warnings about this not being a fairy tale, I do think it reads like a fairy tale for adults (or a scary tale). And perhaps the ending is right for the times we are living. Let’s hope…

So, yes, I recommend this novel to fans of Tremblay, and to readers of horror or dystopian fiction in general. I’d advise readers to check a sample, in case the present tense narration doesn’t work for them, and if you prefer your stories big and your disasters of world proportions, this is not that kind of story. Although the focus is on a couple of characters (mostly), there is plenty of violence, blood and guts, so I wouldn’t recommend it to those who prefer their thrills to be subtle and understated. Also, if you are concerned about reading this story right in the middle of a pandemic and are very anxious about the news, I’d recommend waiting for a while before reading it, because it does hit very close to home. I look forward to reading more novels by this author.

Excellent reference to just about everything you might want a reference for pertaining specifically to gay men's lives. It's well written, interesting, and full with lots of sidebars, diagrams and illustrations/photos. I bought a copy because it's so good. 5+ stars.

Excellent reference to just about everything you might want a reference for pertaining specifically to gay men's lives. It's well written, interesting, and full with lots of sidebars, diagrams and illustrations/photos. I bought a copy because it's so good. 5+ stars.

Received as a First Reads giveaway.Rosalynn Carter's most recent book about mental health care in the U.S. provides a useful, broad picture of the relative lack of progress the nation has made in some areas, notably by cutting corners on Kennedy's plan for deinstitutionalization. However, it also suffers from highly problematic omissions.Carter's overview is good enough to be used as an introductory text for, say, an undergraduate or master's level class in applied psychology, social work, or public policy. However, it paints with a very broad brush and would require active engagement and questioning to be a useful and accurate resource. Carter correctly critiques the relatively brief training in psychology received by medical doctors, but almost completely elides over psychologists, social workers, and other mental health clinicians. As a psychologist, I am dumbfounded by this omission. Psychology and social work are among the mental health professions working assiduously to develop better community-based services that use social, not pharmacological, interventions. Though psychiatrists are at the top of the allopathic hierarchy, it is ward clerks, milieu counselors and nurses who spend most of the day with patients in a residential or day treatment facility. Treatment teams that include all of the staff who interact therapeutically with clients, and truly value all of their perspectives, will better comprehend clients' experiences and be better situated to act in the clients' best interest. All the more so for treatment teams that include the client in treatment planning. This takes time, money, humility, and service delivery structures that do not give the final word to one person, but to the team. Teamwork is a poor fit with the U.S.'s the increasingly capitalistic and individually-focused culture. There is a larger social critique to be made here, in an era where providing for the welfare of others is blasted as "socialism," which apparently is a bad thing.I've worked as a trainee, mental health clinician, and psychologist in a reasonable number of public and private mental health facilities. All had their deficiencies and all were situated within a broader cultural context that lacks adequate wrap-around and gap services, and in some cases, even necessary primary care services for poor people or for everyone. However, in every setting there were more dedicated, concerned staff than otherwise. In most we were poorly paid and tangible and intangible benefits were few. Still, the vast majority of social service, psychology, social work, nursing, and medical staff I've known (and I've known a lot through work at the state and educational level as well as on the ground) have been concerned, kind, conscientious workers. This spirit of diligent kindness and service, especially in contexts where even the best effort will fail due to lack of resources, is not reflected in Carter's book. In those situations where clients and patients have been poorly served, ill-used, and exploited, which certainly also happens with appalling regularity, Carter's main solution seems to be funding. As is well-demonstrated in the literature on infrastructure development, funding is very helpful and a terrific panacea for many problems, but needs to be targeted to the right problems in order to change societal mores, such as stigma. The book is also overly broad and potentially confusing for lay readers in terms of the individual solution of medication. Carter says, incorrectly, that we now know that the major psychiatric conditions are the result of deficient brain chemistry. This is an overly simplified and inaccurate statement, though it's understandable why she lands there; it is a problem of correlation versus causality. We do not know whether a chemical imbalance causes major psychiatric disorders. If we did, there would be a test of, say, dopamine levels that would accurately predict the presence, absence, or potential for a manifested psychiatric disorder. (This is where Carter's analogy of diabetes reaches its limit--a person with diabetes indeed has a measurable deficit of insulin production or cellular capacity to utilize insulin.) Instead, what we know is that in some proportion of cases, by no means all, of a given disorder (e.g., depression, schizophrenia), some people are helped for a period of time by giving them a medication containing or affecting one or more neurotransmitters, in much larger quantities than would be found naturally in the average brain. We also know that not all medications work for people with the same symptoms, and that some cease to work over time (e.g., "Prozac poop-out"). For that group of people for whom the medication works, we find that it addresses the symptoms. Whether it addresses an underlying biological root problem is not clear. To say it another way, we may not be treating a cause of the disorder. To use an analogy, if I am awake for 36 hours and I'm tired, a cup of coffee might make me less tired and more alert, but it doesn't address the cause of my tiredness. It medicates the symptom. Carter is very clear on her belief in the utility of medications, and while I'm all for medicine as one option for potentially drastically reducing human suffering, some of the research literature Carter cites is contradicted by other research literature (e.g., there is dispute about the utility of using versus not using medication to treat an initial psychotic episode). In addition, though she touts medication, many of the interventions she praises are systemic and interpersonal, not biochemical. She correctly identifies the diathesis-stressor model of illness/decreased function (though not by that name), noting the concept that some problems require a physiological vulnerability plus an environmental stressor. However, this does not account well for problems of, say, returning veterans. A person can certainly develop PTSD without a head injury or a biological vulnerability to stress. My two cents: Psychiatric disorders, as we currently construe them, probably arise from a variety of causes and have a variety of courses, even if they are manifested by similar constellations of symptoms and signs. Carter's assertion that the problem is that we know what works and don't speedily implement it has some traction, but not much, since knowing something works in one study doesn't mean it works universally, or even in a second study. On the one hand, it's maddening when lack of funding slows either replication studies or dissemination of viable interventions. On the other hand, I live in a community where there have been a number of dangerous cases of mumps and measles because parents didn't vaccinate their children because of Andrew Wakefield's bogus 1998 study "proving" that the MMR vaccination was linked to autism. As MSNBC notes, "vaccination rates have never fully recovered" (http://www.msnbc.msn.com/id/37311056/). Science is slow, and not without its share of unintentional errors and data cooking.We really need to guard against biological reductionism, which is both inaccurate and obscures interpersonal causes of distress (like child abuse) and societal causes (like poverty or racism). Managed care and the titration of services are largely missing from Carter's book as a targeted and explicitly identified contributor to inadequate services, though from my perspective, this is a major ethical and cultural problem that contributes to lack of services. Again, this primarily but not exclusively affects poor people.Carter argues for comprehensive services, as do I. This means interventions in addition to or instead of medication, and that requires a shift in the medical paradigm common to the U.S. and Europe. It also requires more attention to the kinds of interpersonal and community interventions that Carter gives as examples, but somehow doesn't attribute sufficiently to psychologists, social workers, and other mental health professionals. In summary, this is a valuable and potentially useful book, but it has some significant omissions and errors that need to be discussed to make it an accurate tool to effect change.

Former First Lady Rosalynn Carter has long been a staunch advocate for the mentally ill. In "Within Our Reach," she details some of the reasons that improvements for their care recommended more than 30 years ago still have not been implemented, and why the mental health crisis has escalated.One cannot watch the news or read the papers without seeing stories about returning veterans suffering with post-traumatic stress disorder in numbers greater than ever seen before, and how their promised safety net fails them. TV dramas portray the mentally ill as dangerous (despite the fact that one in four people suffers mental illness and only a tiny minority of such patients are dangerous at all). There is enormous stigma aimed at the mentally ill, which impacts their ability to seek treatment.Carter talks about programs that are helping (she acknowledges that not all people are helped by medication and that psychotherapy is not always available), as well as new technologies that show the hyperactive prefrontal cortex (where thinking occurs) in those with clinical depression. She also talks about the importance of peer support advocacy, where people who have experienced mental illness help others in the same situation.It's not all dry and clinical, though; Carter shares stories from her own childhood, as well as personal histories that mentally ill people have bravely shared with her.This book is an important one to read if you care about the mentally ill in your community, your family and the world.(Review based on uncorrected advance proof.)