Back in the early 80s, when the 12-year-old Charles Graeber signed on to sell Tootsie Rolls door to door for the American Kidney Fund, he never could have envisioned that it would one day help him win the trust of a serial killer. But it may very well have been hearing about this simple act of altruism that led Charles Cullen, a so-called “angel of death,” to grant Graeber access after denying it to every other reporter who’d come before him.
In 2005, Graeber, an award-winning freelance journalist who lives in Williamsburg, stumbled on a newspaper article detailing Cullen’s thwarted attempts to donate a kidney. This was the writer’s first introduction to the case of the New Jersey nurse now believed to be one of the deadliest serial killers in American history, and the man’s crimes were indeed shocking. Using IVs spiked with lethal amounts of insulin, among other drugs, Cullen preyed on what is now estimated to be as many as 400 patients. Still it wasn’t so much Cullen’s horrific past that grabbed Graeber as it was the ethical dilemma at the heart of the article. Was it morally defensible to deny a killer the power to commit a potentially life saving act, even one as monstrous as Cullen?
Graeber was troubled enough by the question to reach out to Cullen in jail. In the letter he wrote he mentioned both his stint as a volunteer for the AKF and the time he’d logged as a medical student and researcher. He assured Cullen that his primary interest was in seeing the greater good prevail, not in holding him accountable for his past. Cullen seemed to believe him. The two men struck up a conversation that lasted for years, years in which Graeber’s interest in the man became more pointed and personal, ultimately resulting in a book, The Good Nurse: A True Story of Medicine, Madness, and Murder.
In The Good Nurse, Graeber tells the story of Charlie Cullen’s transformation from deeply troubled young man to unbridled predator in vivid, unflinching prose reminiscent of true crime classics like In Cold Blood. But the book isn’t just a portrait of a man turned monster, but also of the repeated failure of the hospitals that employed him to stop him even as evidence of his misdeeds mounted.
Last year The Good Nurse garnered critical acclaim and made a number of best-of lists, including the BBC's Top Ten Books of 2013 and Stephen King's "Best Books I Read This Year." I interviewed Graeber prior to The Good Nurse’s paperback release last week. We talked about the genesis of the book, his privileged relationship with Cullen, and the particular challenges of reporting credible and compelling narrative nonfiction.
Charles Cullen has been unwilling to speak to anyone else in the press. Why do you think he made an exception for you?
It was 2005 when I first got involved with Cullen. I wrote him a letter. He talked with me, as he did not with any other journalist, because I think he appreciated that my interest really did lie in facilitating the kidney donation. I told him, straight, that I wasn’t his moral accountant; I wasn’t there to judge him or make an average out of the good and bad in his life. But that I had experience with kidney issues (I’d worked as a researcher for medical papers and had raised funds as a kid) and knew that punishing Cullen by blocking the donation missed the greater good. The fact was another man would die if Cullen didn’t donate that kidney.
I put the power to respond to his critics in Cullen’s hands. I also acknowledged that he wasn’t probably much interested in talking to the press and said I couldn’t blame him. These two things combined, I think, made him see my letter as a chance to advance his own agenda. I didn’t judge that either. But it did give me access, and from there, the ability to tell the story as it had never been told. But I was very much aware of my own potential moral pitfalls here. I wouldn’t lie to him. I wouldn’t pretend to be a friend. I did laugh at his funny stories—and he has some genuinely funny ones. I did want to use the bully pulpit of the press to aid his getting that donation done, to save the life that depended on it—and so did he.
What is your relationship with Cullen like? In the book, you suggest that once he was cornered he actually got some satisfaction out of telling his own story to the police. Was he eager to speak to you?
At times. He’s a complicated guy, and doesn’t do anything he doesn’t want to. He was, at times, eager to talk about things, but only those things he was comfortable broadcasting. The full story—the one that emerges in the book—was something he didn’t want known.
When I came to see him in jail, behind the scenes during his sentencing, and later behind the plate glass of Trenton Maximum Security prison, he would sometimes give a little smile and wave and have a number of things he wanted to discuss. When I did steer the discussions into less comfortable waters, he got fidgety and would almost shut down. In those moments, his eyes would go, his face would sag. He was, in a way, disappearing. Where he went, I couldn’t say.
What aspects of his life was he most resistant to discussing and how did this impact the way you reported the book?
Much of what I gained in talking to Cullen was insight into his thinking. He’d refused the FBI profilers from Quantico and, of course, his psych evaluations are privileged. And because he wouldn’t speak, nobody had really even heard his voice, much less had a sense of the way he thought about his crimes, the sort of logic he applied. Hearing his stories, the manner in which he got excited about certain things and how he avoided speaking about others, his blame—his sense of indignation and moral superiority about how the hospitals failed to catch him—that was the greatest insight.
What he didn’t ever discuss was murder. He didn’t call it that and I didn’t push it. If we ever went directly at the murder question or I pressed for details outside of a clinical context—if we went into the emotion of the moment—he would shut down. Involuntarily, it seemed. He simply couldn’t or wouldn’t go there. I was able to get many of the details in the book by talking to him about everything surrounding the murders rather than the fact of murder itself. And his willingness to engage with me in this way—his ability to coolly disconnect the technical details from the lives taken—was, in some ways, the most instructive insight of all.
Cullen maintained that his crimes were driven by a wish to alleviate suffering. After spending all this time with him, do you believe this or do you think he is a true psychopath? He comes off as a real cipher, equal parts victim and monster.
Yes. He’s a complicated person. That’s part of it. But people are complicated. Cullen had something more akin to a gambling habit—more of a compulsion than a homicidal need in the way we’d traditionally think of it. I’m not a psychologist, don’t pretend to be one in this book, and I couldn’t give you a true clinical diagnosis. But it’s clear that for someone to have a compulsive habit based on playing with—and destroying—other people’s lives is a hallmark of exceptional narcissism, if not psychopathy.
It all fits with the notion of being both villain and victim. He’s allowed, in his thinking, to lash out, to act out, because he’s a victim. But the consequences of that ‘acting out’ resulted in the death of many, many innocent people, time and time again, over 16 years. Understanding compulsion, empathizing with it on some level, is not difficult, I found, and I think readers find the same. What’s not possible to empathize with is the toll on others lives. It would register differently for most people. For Cullen, it didn’t register hardly at all except in how it affected him, or reflected upon him.
Much ink has been spilled in recent years about the need to draw clearer lines between fiction and nonfiction (see Frey, et al). I was thinking about this as I read The Good Nurse, because, like In Cold Blood, you employ a lot of novelistic devices, such as recreating scenes and dialogue. Did you define clear rules for yourself about where you needed to be strictly factual and where you were allowed to embroider or “reimagine” things through a character’s eyes for the sake of the story?
Absolutely. I had many discussions with other journalists and nonfiction writers, and many with editors and my publishers, about exactly that. I was very concerned that the book be an absolutely rock solid work of responsible journalism. At the same time, I was determined that a character’s unwillingness to speak candidly not make the story untellable—or rather, unreadable. The main players in this story—Cullen himself, the hospitals at which he worked, even the detectives and the confidential informant—had all been relatively (if not completely) silent prior to my research, which meant there were a lot of blank spots to fill in.
Part of what I did to help with the novelistic sensibility was to rely sparingly on quoted dialogue by burying the dialogue in the narrative as “voiced” third person. But I did want to use all the devices available to a writer without stepping over the line of the truth. And so, yes, I made rules. For example, I noted where dialogue was, by necessity, recreated. I did not recreate dialogue that I couldn’t back up with eyewitnesses or court documents, such as interviews and depositions. With the dialogue I did recreate, I even took the unusual step of showing the detectives all of their recreated dialogue to ensure that I’d gotten it right. At issue were not the facts, but the speech itself.
I also made sure to spend plenty of time in all the settings for this book, and to research everything, right down to the color of floor tiles or the weather in micro-region on the current day, in order to be able to use those details. I didn’t use everything I found of course, but having mastery of those details, knowing the world of which I was writing, made the tone possible.
But yes, I was acutely aware of the potential pitfalls of reaching too far in a scene, wanting to color in the world as I could not journalistically. A great deal of the writing time—one of the reasons this book took years—was my need to find just the right way to write scenes and structure the story so that I could move from truth to truth without seeming to be intentionally hopscotching only between islands of possible reportage. Making the world of the book as seamless as any created by a fiction writer was the challenge, and a large part of my mission, artistically. This book has important truths, which need to be exposed to the public. But in order to effectively educate, in order to keep a reader, I had to capture their attentions, and allow them to live this book, and experience the events, the tensions and emotions, in a manner which simple news cannot.
The back of your book is brimming with endnotes. Was this an attempt to counter any questions about its authenticity from the outset?
The endnotes served many purposes. One was to provide a place for editorializing and the authorial voice, which I wanted to keep out of the main flow of the book. Another was to give a home to the years’ worth of reported details, which might bog down the flow of the narrative, but which many readers—and, certainly I—might find illuminating and fascinating. The third was journalistic, yes. I knew that in using novelistic devices to frame certain parts of the telling, I might be casting doubt on the journalism behind the scenes. And so I wanted to provide a means for the reader to verify the verity of those details for themselves. And, if they chose, to dig deeper.
There are really two villains in this book: there’s Cullen and there is the hospital system that repeatedly failed to stop him even when presented with compelling evidence that he was harming people. How culpable do you think hospital administrators were in the deaths of Cullen’s victims? Does the fact that he was allowed to keep bouncing from hospital to hospital strike you as more of a moral or an organizational failure?
I leave it to the reader to come to their own conclusions on that. Part of the reason I believe this story has not been previously told, at least not in such detail, are the obvious legal pitfalls of bringing whistleblowers into the light and making conclusions not backed up by the courts. So I took it upon myself to lay out all the facts in a manner which made even this dense and complicated story possible (and hopefully entertaining) to allow readers to evaluate the actions of the hospitals for themselves.
That said, there were certainly repeated institutional failures. And that’s understandable, if lamentable. Institutions are worlds in themselves. There’s a tendency for corporations, including hospitals, to attempt to address issues internally before exposing themselves to the outside world. Fear of liability is not irrational. And it takes a great deal of imagination for anyone, a nurse or administrator or a patient, to imagine the worst—that someone, garbed in the uniform of care, was murdering innocents.
The moral failure question is definitely one I wanted the reader to decide. I believe the book equips them to do so. And I believe it’s reasonable for the public to ask that the actions of administrators at some of the hospitals be vetted by a grand jury. I think transparency and accountability are not too much to ask from such a complex and tragic failure. Certainly, it’s possible. There is no statue of limitations on criminal misconduct at the administrative level, if a court was to discover it.
This book required you to report an enormous amount of detail that could be relatively dry if dealt with incorrectly—things ranging from Charlie’s endless job hopping to the workings of the medication dispensing system, Pyxis, to the lab reports poured over by detectives. Was it a struggle to maintain narrative momentum while wrestling with all this data?
Part of the process of writing this book was massive overwriting—to make sure the chronology was complete and correct, and that the reader was given enough information to understand what was happening despite the preponderance of technical and scientific data.
Structure was an enormous challenge—making the details readable, as well as true. Once I had the full scope of the story written out, I made further choices about when to reveal certain information, and more critically, what details needed be struck from the book in order to keep it from being repetitive or dull. If the weapon Cullen used had been a gun, I wouldn’t have had to explain it. But Cullen used drugs with which most readers are utterly unfamiliar. At some point in the story, I had to explain those drugs, their action on the body, some element of the pharmacopeia. It’s fascinating stuff but I was aware it could easily overwhelm the flow. I tried to introduce something with its bottom-line importance first. Once we know that a thing matters, I find there’s a greater appetite for learning about it. Eventually, we’re ready to fully geek out on the chemistry, or the science—it matters at that point; we’re invested. Same with characters—we have to know why we care before we really want to meet them in earnest.
This was a huge challenge even in presenting Cullen’s personal history. A perfectly chronological book would have hundreds of pages of Cullen’s early life. I had that, at one point. I ultimately pulled that, burying the most critical elements of his backstory later in the book, once we were caught up to the near present tense of the story and cared more. It broke my heart to do that. But it was necessary to keep the flow going. One of my greatest assets as a writer, I think, is my total intolerance of boring writing. I just can’t get through it. I’m handicapped by my own attention span. But when I’m able to go back through my work after cooling off from the heat of the writing, my short attention span is an asset. If I find myself wandering, if I’m not hooked on every detail, then that detail can’t live there.
There is a rash of violence these days committed by damaged, disaffected white men much like Charlie Cullen. Unlike the mass shooters you read about, Charlie's crimes were covert, but his acts overlap with theirs. He felt himself to be the victim rather than the perpetrator and felt the need to seek retribution by targeting a largely random group of strangers. Have you thought about these parallels and what societal factors are feeding this type of crime?
I haven't, frankly, though the parallels are clearly there. Technology plays a role. These mass killings feel cinematic because they are. How many years ago would we have never imagined the concept of a close-up, never imagined that the eye of God or the lens of the world could be zoomed tight on our life and broadcast? These days anyone can go viral via meme, GIF or trend. This is an entirely modern phenomenon, this democratization of messengers. You don't need to assassinate an Archduke to make the “front page” anymore.
This does nothing to explain why people have bad ideas in their heads in the first place, why they choose violence as a message, why they devalue the lives of others. It doesn’t explain our basic cravings for love and attention or the need we feel to affirm our own existence. But for me anyway it contributes to why people decide to make their private pain so public. It goes part of the way in explaining why some of us get caught up in fantasies of a Valhalla of virgins and palaces, an afterlife of many rooms and cups of ambrosia and access to Grandma and Fido forever, heaven, or the vision of yourself trending, breaking, and played on DVR Dharma road with cool background music—it doesn't feel so different to me.