Catharine Coleborne on Emily K. Abel’s *Sick and Tired: An Intimate History of Fatigue*

Emily Abel’s book Sick and Tired: An Intimate History of Fatigue, is framed by her own personal account of fatigue following her recovery from breast cancer. It is an intimate story that opens the focus on fatigue as historical subject. It does this by showing the closeup view of the way personal lived experiences of deep exhaustion – subjective knowledge of illness – have been denigrated in the context of societies bent on productivity and triumphing over sickness. Abel uses this approach to good effect to tease out the complexity of an illness without a firm diagnosis, or within an emerging language to describe fatigue over time.

The curiosity presented by fatigue and its link to malingering or to suspect and diffuse symptoms means the reactions to the idea of fatigue have been produced in relation to social as well as medical concepts of illness conditions. It is strange, elusive, and invisible, and yet is terribly palpable to the sufferer, and it plays into social fears about becoming a non-person in the world of busyness and endless work and activity. Fatigue allows Abel to write about the way the ‘sick role,’ imagined by Talcott Parsons in 1951, changes in the case of the chronically unwell (22). She brings in a host of voices including medical anthropologist Emily Martin, historian of pain Elaine Scarry, and many other scholars, to help her examine fatigue.

In seven chapters, Abel examines fatigue as lived experience, as historically contingent concept, and as an illness. The grouping of topics and themes is novel. Neurasthenia, industrial fatigue, stress, burnout, and sleepiness fold into one narrative of the history of fatigue. Historical attempts to counter fatigue appear in a chapter on rest: the rest cure, leisure, sleep itself all become objects of the quest to understand the dimensions of fatigue over time. More strident forms of combatting fatigue through vigorous activity tell us that as with other illness conditions, humans have tried to ‘fix’ the body by driving it, this time with exercise, energy boosters and substances. The memories of fatigue are presented in a chapter about the psychosomatic illness and polio, with polio a more serious bodily disease affecting many people before the polio vaccine halted its devasting impact. Polio has received rather more historical attention, including in works that seek to remember and document the illness experience through memoir, such as the influential writing of Kathryn Black, but also lesser known but equally vital memoir. These were shaping experiences of the twentieth century. Finally, Abel ends her book with a chapter that brings together her search for an answer – some diagnostic clarity – by reflecting on the power and value of stories about health and illness, tied in with the rise of health activism. Her book therefore acts as a fascinating look at the way illness and medical explanations grew across the arc of the last 200 years, with our ways of thinking and writing about health and illness also dynamic.

The book establishes the premise that fatigue is both ‘real’ and socially produced or inflected. Published before the rise of the discussion about ‘long COVID’, the book takes ‘burnout’ as one example of a new ‘diagnosis’ that might be just as contested as ‘yuppie flu’ was once when it appeared in popular thinking about illness phenomena. Burnout, a diagnosis that appears in the World Health Organisation’s classification of health problems, has made a reappearance in recent times, though Abel shows it has a longer history that reaches back to the 1960s and 1970s and was mostly associated with the stressful conditions of social assistance and caring professions; an additional descriptor of ‘compassion fatigue’ points to how it has been framed.

Further defined in the 1990s as awareness of trauma-related conditions grew, burnout has made a return during COVID. This is presumably because of the prevalence of middle-class people working from home and juggling family caring responsibilities without respite; middle managers and upper management staff were also tasked with managing remote workers through the pandemic crisis. Burnout has hit the nursing, medical and ancillary care workers most of all.

Meanwhile, ‘yuppie flu’, first proposed as a syndrome affecting people who were possibly just ‘stressed’ or ‘burnt out’, highlights the trajectory of one diagnostic label over time. Abel examines the history of chronic fatigue syndrome (CFS), at one time known as ‘ME’ for myalgic encephalomyelitis. Abel does not readily evoke ‘yuppie flu’ as a label but looks instead at the developing understanding over time of CFS for sufferers and clinicians. For Abel, studies and trials related to CFS fall short of nailing the ultimate understanding of ‘fatigue’ as a physical illness, as explored in Chapter 7. Here, Abel relates her inquiry to the changing intellectual environment, finding possibility in the rise of critical disability studies. The frames provided by scholars including Arthur Frank help Abel to find reassurance and validity through narrative as she comes to terms with the chronicity of her experience with fatigue, which was not going away. Maybe the need to understand it as a firm diagnosis of the body, Abel admits, was not the point.

Reading this book, I find it very interesting that depression has often been seen as an available label to understand fatigue. Depression itself – with symptoms such as tiredness, lack of drive and despondency – was not always well understood, but it has become part of a mainstream language of illness over time. Abel remarks that being confused with depression was not always productive in the case of fatigue. Fatigue is overwhelmingly a physical experience for most people who simply struggle to recover their energy to do as much as they want to do, marking it out from depressive states of mind that cause lethargy.

On pain, it, too, like depression, has become an available way to ‘reach’ fatigue, mostly because studies of pain and self-reporting of pain are more advanced. It is fascinating to read about the way pain scales developed over time and remain highly subjective.

One slight weakness of this book lies in its rushed and survey-like approach to examples. This is especially so in the early chapters, with everything from the names of scholars, other studies, and famous moments or commentary thrown in as evidence to support the claims being made about the history of a general disregard for fatigue as a real illness experience. The book improves when it slows down to develop ideas and considers its separate thematic threads, but it still tends to be written on the surface of the body of evidence. Abel gives the impression of wanting to mount a case.

Allied to this problem, there are times when Abel’s personal account also threatens to overwhelm the study. Where the intimate becomes useful is in the connection between the histories of pain (subjective and personal) or in the historical narrative of discursive frames for understanding our bodily limitations, from rest to exercise and the psychosomatic. Yet I acknowledge that Abel herself has found narrating her experience to be valuable as an intellectual and as a sufferer.

Being part of the ‘Studies in Social Medicine’ series means the book is working hard to create a vision for fatigue as an illness that allows us to read and interpret social change and diagnostic labels in historical context, especially in its provision of interpretations of the meanings of fatigue including neurasthenia, polio, and chronic fatigue syndrome along with a range of other entry points to illnesses allied to excessive tiredness.

Abel’s efforts here are useful. Yet the book’s race through time and episodes, without depth in any specific medical or cultural roots for a model for fatigue, leaves me slightly uneasy. Abel is not claiming a teleology here or asking us to see different illness labels as historical manifestations of the same condition or experience: in this way, the book is not telling the story of one disease label that changes over time, but rather, examining how we might find, see, and understand fatigue and its meanings at different points in history, and inflected by our own context.

On that note, the book ends with some helpful insights about the fact that diseases and diagnoses change over time, which in turn can affect our experiences of them. I liked her point that the emphasis on triumphal medical stories has obscured histories of hidden illnesses. Finally, the book also offers up views about work and labour that remind us of the context of an almost relentless drive towards productive bodies. Is it possible, Abel asks, if in our quest for conquering illnesses like cancer that we rush to conclude we are well and recovered, when in fact symptoms of illness remain and linger in an often quite prolonged aftermath to treatment? Fatigue affects leisure time, too, and marriages, and being a parent; these observations are reflected throughout the book and have appeared in current reports of long COVID. The documentation of this thread should form a new focus for Abel if she updates her book in future. A newer book by Georges Vigarello (translated by Nancy Erber) has appeared in 2022: A History of Fatigue: From the Middle Ages to the Present (Polity). While not the focus of this review, the pairing of these books suggests a new area of inquiry ripe for further examination.