The People's Hospital: Hope and Peril in American Medicine

The People's Hospital: Hope and Peril in American Medicine

by Ricardo Nuila
The People's Hospital: Hope and Peril in American Medicine

The People's Hospital: Hope and Peril in American Medicine

by Ricardo Nuila

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Overview

“Nuila’s storytelling gifts place him alongside colleagues like Atul Gawande.” —Los Angeles Times

This “compelling mixture of health care policy and gripping stories from the frontlines of medicine” (The Guardian) explores the question: where does an uninsured person go when turned away by hospitals, clinics, and doctors?

Here, we follow the lives of five uninsured Houstonians as their struggle for survival leads them to a hospital that prioritizes people over profit. First, we meet Stephen, the restaurant franchise manager who signed up for his company’s lowest priced plan, only to find himself facing insurmountable costs after a cancer diagnosis. Then Christian—a young college student and retail worker who can’t seem to get an accurate diagnosis, let alone treatment, for his debilitating knee pain. Geronimo, thirty-six years old, has liver failure, but his meager disability check disqualifies him for Medicaid—and puts a life-saving transplant just out of reach. Roxana, who’s lived in the community without a visa for more than two decades, suffers from complications related to her cancer treatment. And finally, there’s Ebonie, a young mother whose high-risk pregnancy endangers her life. Whether due to immigration status, income, or the vagaries of state Medicaid law, all five are denied access to care. For all five, this exclusion could prove life-threatening.

Each patient eventually lands at Ben Taub, the county hospital where Dr. Nuila has worked for over a decade. Nuila delves with empathy into the experiences of his patients, braiding their dramas into a singular narrative that contradicts the established idea that the only way to receive good health care is with good insurance. As readers follow the moving twists and turns in each patient’s story, it’s impossible to deny that our system is broken—and that Ben Taub’s innovative model, where patient care is more important than insurance payments, could help light the path forward.

Product Details

ISBN-13: 9781501198045
Publisher: Scribner
Publication date: 03/14/2023
Pages: 384
Sales rank: 58,364
Product dimensions: 6.20(w) x 9.10(h) x 1.20(d)

About the Author

Dr. Ricardo Nuila is a writer, teacher, and practicing doctor. He is an associate professor of medicine, medical ethics, and health policy at Baylor College of Medicine, where he directs the Humanities Expression and Arts Lab [HEAL] program.

Read an Excerpt

Chapter 1: Histories — 1 — Histories
The rumor we heard was that patients arrived with hand-drawn maps, our hospital marked like treasure. The stately Nigerian lady who responded, “Yes, Doctor,” to everything (metastatic breast cancer). The boy with the black curly hair wearing red Converse All Stars and a Judas Priest T-shirt that screamed Mexico City (acute lymphocytic leukemia). The grandmother with the sari snagged in the guardrails (chest pain, real chest pain, might need bypass). We stood at these patients’ bedsides; we wrote down their histories; we said we were sorry for examining them with cold hands. We ordered blood tests, interpreted EKGs, scrolled through their CAT scans; we input diagnoses.

We weren’t just doctors. Among us were nurses, social workers, X-ray techs, the people who rode up and down the hallways in the middle of the night waxing the floors. Some of us wore white coats with frayed sleeves and busted pockets, others tight-fitting scrubs embroidered with our names. In our bad moments, we became tribal: we weren’t “we,” we were ortho, medicine, plastics, the 4A nurses; we only covered the unit. More often though, the needs of our patients were so damn immediate, we found a way to work as one.

We ran blood transfusions, heparin drips, a morphine pump when Norco didn’t touch the pain. When COVID came, we gave oxygen together, one of us twisting the knob on the valve while the other inserted those tiny prongs into flared nostrils. We consulted one another when things looked dicey: surgery if we found boils, ID for antibiotics, and if anything looked remotely like a seizure—a twitch, a rolling of the eyes—we paged neurology overhead. If Transportation was swamped, we wheeled them ourselves, to MRI, to Special Procedures, to the cath lab, even the ICU (how downtrodden we looked when we did this, like beaten dogs).

We figured out ways to make things work. Not enough money for your meds? We googled the $4 list at Walmart. Muscles too weak? We dug up a refurbished walker from the basement. Dying and homeless and alone? We called in a favor from the hospice that used to be a Tudor-style home. And when our work was done, once we could envision someone not dying within twenty-four hours of our discharge order, once the first chemo had gone in, once we could be sure their chief complaint was addressed, the thought still lingered in our minds: What brought them here? What are their stories?

Ben Taub Hospital. The largest safety-net hospital in one of America’s most diverse cities. We are Heathrow if you replaced the Emirates and the Virgin Atlantic planes with Greyhound buses. There are no atriums with pianists here playing “Here Comes the Sun” to welcome you, no soothing sounds of running water from hidden speakers or—gasp—from an actual indoor waterfall. There is no Starbucks. Our cafeteria serves some form of barbecue most days for lunch and packaged salads topped with egg or chicken strips. That’s unless you prefer the full-menu McDonald’s (located inside the hospital) that’s open twenty-three hours a day. We do have a gift shop, though it looks more like a convenience store, heavily stocked with greeting cards. Not the pun-filled ones; rather, the kind that get the point across—condolences—available in Spanish, too.

If you type “Ben Taub” into Google Maps, you’ll find it crammed between the Houston Zoo and the thirty other institutions that make up the Texas Medical Center, the largest concentration of medical facilities in the world. Some of the field’s most important innovations took place in this medical metropolis: the first successful bypass, the first artificial-heart transplant, the first beatless artificial heart (imagine that, no lub-dub, just a constant whirring), the first silicone breast implant, one of the first civilian helicopter ambulances, the Bubble Boy—all here.

Not that the patients at Ben Taub know this. Some may have heard that MD Anderson is rated top in the country in cancer care, or that at Houston Methodist, you might find yourself fortunate enough to have a robot operate on your prostate (the TV ads air in Spanish, too). It’s possible that at night, our patients look out their windows and behold the sparkle of so many new glass buildings, some of them named after billionaire sheikhs who sell the oil that becomes their gas. More likely, they’re looking out in the direction of the zoo, toward the parking garage and bus stop, wondering how they’ll get home.

Ben Taub is Houston’s largest hospital for the poor—many working, some not—who cannot afford medical care. That is, after all, the definition of a safety-net hospital: one that serves society’s most medically and financially vulnerable. The vast majority of hospitals in the US are either for-profit or nonprofit. Nonprofits receive a tax incentive to provide care to the uninsured, though that care is often limited to stabilizing emergencies due to the high cost of medical care. For-profits behave similarly. Safety-net hospitals have emerged in America’s coverage vacuum to give the uninsured a way of receiving healthcare. Ben Taub is a public, locally funded hospital that focuses on the uninsured but that is also open to people with health insurance.

In Texas, the state with the nation’s largest uninsured population, and perhaps the worst state in the union to live in if you’re poor and chronically ill, scores of people come here. When they do, the community picks up half the tab through property taxes. The rest comes from a variety of sources, including Medicaid, Medicare, and payments made directly by patients. Ben Taub is the flagship hospital for Harris Health, the healthcare system catering to Houston’s uninsured patients. Five hundred sixty people stay at Ben Taub or Lyndon B. Johnson Hospital, its sister hospital, every day, and thousands more receive primary and specialty care at the county’s network of clinics, accounting for more than $1 billion worth of healthcare every year for the indigent.

But there are instances when the insured and even the rich prefer Ben Taub. Whenever I mention to locals that I work as a doctor at Ben Taub, I receive a fairly typical response: “That’s where I’d go if I got shot.” Maybe this sounds uniquely Texan, but I’ve heard the same about traffic accidents. Whenever there’s a pileup on the freeway, it’s not uncommon to hear the radio announcer report something like, “Crews on the scene, the victims have been taken to Ben Taub.” Ben Taub’s reputation in Houston is nothing short of sterling when it comes to trauma care, which is why it’s not uncommon to find the crushed, the burned, the dismembered, the stabbed, the shot up, the opened, the clipped, and the repeatedly tased sharing a room with patients beleaguered by mental illness and poverty.

People outside the medical field might wonder why anyone would want to work in a place like this. Why deal with so many social problems and a lack of insurance when you can practice in one of the many hospitals down the road? Aren’t you ambitious? You’d have to be some sort of a do-gooder—a bleeding heart—to work here, the thought goes. This sort of characterization, however, while flattering, isn’t entirely accurate. Take Dr. Ken Mattox, a trauma surgeon at Ben Taub who served as its chief of staff for over thirty years. Mattox is what you might call a quintessential old-school surgeon—he’ll wear scrubs only in the OR and on call nights (never at restaurants), he’s always cleanly shaven, and he moves methodically down the hallways, even on the way to his patients awaiting exploratory laparotomies for multiple gunshot wounds. Because there’s never a need to rush.

Like many Texans, Mattox opposes the federal government’s issuing regulations that can encroach upon local practices. The mandate to purchase private health insurance in the Affordable Care Act irked him, for instance, because patients at Harris Health already received coverage without having to buy insurance. He can sound like an ideologue when speaking about welfare—“I don’t want to take care of somebody that is indigent who is capable of working and making their own way”—but Mattox has dedicated the bulk of his career to ensuring Houston’s indigent patients receive excellent care. This includes undocumented immigrants.

In fact, in 2001, when then–attorney general and current US senator for Texas John Cornyn wrote a legal opinion about how Ben Taub and the county health system might have been breaking federal law by providing nonemergency treatment to the undocumented, Mattox addressed Harris Health’s board of managers, who were fearful that federal funding might be cut off. “If I need to be reported for my clinical care, report me,” he said, insisting that services to this population ought to continue. “But spell my name right.”

A whole array of competing ideologies collide at Ben Taub. But when it comes to caring for uninsured Houstonians, the healthcare workers at Ben Taub—doctors included—put their political philosophies aside, for good reasons.

Ben Taub is an excellent classroom. It’s where the diseases and maladies you read about in textbooks come to life, and it’s intended as such—Ben Taub is a designated medical education site, and many of the stiff white coats you see scuttling down the hallways are those of students and young doctors in training. You might spend a lifetime with patients at private hospitals without seeing belly tuberculosis, or even cardiac sarcoidosis, where all the cells infiltrating the heart glimmer on the ultrasound. If you spend enough time at Ben Taub, you’ll see most everything. It’s why many young doctors with meticulously mapped-out careers, who are on their way to Harvard or San Francisco or the National Institutes of Health, make a pit stop here. The illnesses you see and deal with at Ben Taub make you a better doctor.

But more than this, healthcare workers feel useful at Ben Taub. Much of this sense of utility stems from helping those most in need, but another part comes from working in a system that takes healthcare spending seriously. America spends a larger percentage of its gross domestic product on healthcare than any country in the world, more than double, in fact, what Japan, Canada, or any western European nation spends. What that money buys is expansive and comprehensive healthcare for some—including the newest combination pills and robotic surgeries and transplants—and expensive but mostly ineffective emergency care for those who cannot afford high-end care. In 2015, Ben Taub Hospital and Harris Health spent a little less than half the national average, around $3,365 per patient, costs that included emergency, specialty, and primary care. Compare that to national health expenditure data that showed nearly $10,000 spent per patient (Medicare spends nearly $11,000 per patient). To put that in perspective, a healthcare system in Texas dedicated to the poor has found a way to buck the American trend and treat patients as efficiently as French, German, and other healthcare systems regarded as the best in the world. Some doctors, like me, are proud to work in one of the few systems in America that doesn’t make healthcare more expensive for those who pay already-inflated prices and premiums—which is to say, all of us.

These savings wouldn’t amount to much if Ben Taub provided subpar care. But expensive care doesn’t mean better care. In fact, at Ben Taub, you often find the opposite: the best medical care is the most affordable. In 2015, Ben Taub demonstrated itself to be the best hospital in the country for treating heart attacks. Heart attacks are essentially like a dying lawn: Imagine a kink forming in the hose you use to water your yard so that only a trickle of water comes out the nozzle. In the hot and dry summer, unless you fix the kink, the grass will start to turn yellow and slowly die. Now imagine that same process happening over not days but minutes. Imagine the blades of grass are individual heart muscle cells, the hose a coronary artery. Heart cells start to die when the artery is kinked with a clot. A patient feels stabbing chest pain, and so she comes to the emergency room, whereupon a stopwatch starts—how long does it take for the hospital to identify the coronary artery and unkink it? This is how the quality of heart attack care is measured: the sooner the coronary artery is unkinked (through a procedure called a percutaneous coronary intervention), the more heart cells are preserved, the greener the lawn.

On average, it takes hospitals around ninety minutes to figure out if a coronary artery is kinked and to unkink it. Top-rated centers equip themselves with numerous suites to perform this unkinking—called cath labs—and enlist armies of cardiologists. These well-funded sites tout their US News and World Report ranking in heart attack care, but the actual outcomes say otherwise. With only four cath labs—two permanent, two convertible labs—and three full-time interventional heart doctors, Ben Taub unkinked arteries in an average of forty-five minutes, the fastest time in the nation. Greener—no, greenest—lawns.

The question is, how? How is Ben Taub able to provide these scores of patients with this level of lifesaving care? How does it provide primary and specialty care, including chemotherapies and expensive HIV medicines, to patients who can’t otherwise afford it or who don’t qualify for insurance through the Affordable Care Act? If you consider that only 7 percent of Ben Taub’s patients have private health insurance and another 20 percent have government-sponsored coverage through Medicare or Medicaid, leaving a full 63 percent of its patients completely uninsured, how is it possible that a hospital without ample private funding and chandeliers and a pianist in the atrium can give its poor patients great heart attack care?

Is expensive healthcare better or is it just more expensive? Can we trust public hospitals in America? Why can’t people access healthcare when America has so many entitlement programs? This book attempts to answer these questions and more. In my twelve years at Ben Taub, I’ve found that good care comes from connecting with your patients in whatever way you’re able. As a medical student, connecting meant translating for the Spanish speakers. It meant occasionally dropping hints about my own roots (“What part of El Salvador are you from?”) and always referring my patients’ questions to my bosses, the real doctors. As an internal medicine resident scurrying through Ben Taub’s halls, it meant being physically present for my patients when they needed me. It also meant learning more about people’s lives, asking questions—“Did you cook with wood inside your home?”—and being honest when I didn’t know the answers to their questions.

Since I became a teaching attending and hospitalist at Ben Taub, connecting has meant not only performing all my duties as a doctor but also uncovering and understanding the policies that both limit and enhance my patients’ care. Why doesn’t Mr. Oregón qualify for Medicaid? How often should I tell Rogelio to visit the ER for recurring lifesaving treatment? Is it helpful or harmful to recommend that Christian apply for disability? Will prescribing a more costly medication roil Roxana’s already all-too-difficult life? Would a lesser-quality medicine be better, all things considered? By telling the hospital’s stories of illness, poverty, loss, convalescence, hope, and more, this book will delve into how Ben Taub and Harris Health provide affordable and excellent care.

This isn’t to say that Ben Taub is a panacea. After all, Texas is Texas, quite possibly the most restrictive healthcare environment for the poor in the country. Ben Taub and safety-net hospitals like it are good at providing a basic level of healthcare to the greatest number of people. But some treatments, like transplant surgeries, are still too expensive, and some specialty care, like kidney stone surgery, is too scarce. There are larger issues as well. The safety net’s latticework is extremely fragile in its dependence on local politics. Ben Taub serves as a model for how to blend conservative values with compassionate care, which is vital for a blue city in a red state. In many ways, the county has figured out a way to hit the bull’s-eye of providing excellent care at cut-rate prices. Other times, the Texas Legislature’s refusal to expand Medicaid, which pushes more responsibility and costs onto the local safety net, leads to broken lives. These patient stories will show the individual realities of political decisions.

This book will not be the first to chronicle how Ben Taub provides care to Houston’s indigent. In the early 1960s, Houstonians unable to afford healthcare faced obstacles of epic proportions:

The smell of poverty cannot be described, although it is the same all over the world. I had smelled it in India, in Paris, in prison camps during the war, but most unforgettably when the first inmates of the Nazi concentration camps came home after their liberation... I had seen well-intentioned humanitarian officers start out by trying to treat them as unfortunate human beings. Before the day was past, they were yelling at them, herding them, pushing their milling, mindless mass around as cowboys push a herd of cattle. I suppose they ended up that way because of the impossibility of identification. It was impossible for normal, civilized men to identify with those stinking, unshaven, dirt-caked, lice- and disease-ridden human wrecks... I had forgotten their smell; it hit me again, after all of those years, as I entered Jefferson Davis Hospital in Houston, Texas.

The author of this passage volunteered at Ben Taub’s predecessor, Jefferson Davis Hospital, for nine months in 1963, changing bedpans when instructed, wheeling pregnant women to safe spaces, sitting like a blue-eyed fly on the wall when doctors and nurses entered the room and took over. He was also a novelist, a playwright, a nominee for the Nobel Prize in Literature, a ship captain who had rescued flood victims, a Quaker, a Nazi resistance fighter, a Dutch war hero, and a visiting creative writing instructor at the University of Houston. His name was Jan de Hartog, and his book The Hospital described the transition from Jeff Davis to Ben Taub, from a dilapidated building manned by trainees to a multispecialty center staffed by some of the country’s top doctors, from a house of charity to a civic institution, from segregated wards to an edifice whose name rings with hope in households across Houston. De Hartog’s words alerted the city to the deplorable state of its safety-net hospital, and the community responded in the mid-1960s with a vote to give healthcare access to everyone living in the county.

Fifty years later, this is the story of what Ben Taub Hospital has become and what it means. This book is an update to de Hartog’s as much as it is a foil. Has a locally funded healthcare system served Houston’s uninsured well? Do competing ideologies like universal healthcare—even for the undocumented—and cost-cutting actually coalesce at Ben Taub? Can our system help the country figure out how to extend good healthcare affordably to everyone?

Early in my career, during my internship, I was slated to take care of patients on Ben Taub’s general wards, meaning those hospitalized for some degree of organ dysfunction—kidney disease, liver cirrhosis, pneumonia, infections of the skin. Every morning, I pulled into work listening to a Wilco song. I wasn’t superstitious, but one particular line seemed to encapsulate all the illnesses I was witnessing and my general feeling of ineptitude, and it comforted me to recite it: “Maybe I won’t be so afraid.” I have no idea when this ritual stopped.

I arrived on the wards and printed out a list of my new patients. Then I visited each hospital unit and started reading through the charts. Everything was paper back then, meaning you could flip and flip and flip—through orders, test results, the notes of other doctors—and still not get to the bottom of what exactly was happening. One patient had a particularly large chart, actually two charts duct-taped together: Alvaro. It was so heavy and had been flipped through so many times that, like on an old book, cracks had started to show in its gray spine.

I read about Alvaro’s many surgeries: hip surgery, belly surgery, large portions of his intestines removed. For months, he couldn’t eat, his only nutrition delivered through an IV and then a tube in his stomach. It started as colon cancer. It had spread throughout Alvaro’s body to multiple organs and joints. Over the prior nine months, he’d spent only a couple of weeks out of the hospital. Otherwise he was in the ICU, then the wards, then the ICU again with septic shock from an infection of the blood, then a rehab center, then again the ICU. And now Alvaro was here on the wards, in Ben Taub, my new patient. After flipping through the chart, I draped a stethoscope around my neck and went to meet him.

“English or Spanish?” This was the first important question I asked.

“Español,” he said.

When I was a medical student, professors used to praise me for the translations I provided. They had no clue. I’m the son of Salvadoran immigrants and, as such, grew up with Spanish everywhere—at the dinner table, at my parents’ parties, every summer visiting my grandparents in the hills outside the capital. But apparently reading and studying English influenced me more, and I speak Spanish like a gringo. It is something I’m constantly aware of, a part of who I am and how I’m seen, like a tic. Except at Ben Taub. The patients here rarely mention it. Even my Spanish is music to their ears.

“Any bleeding?” I asked.

Mr. Alvaro shifted his head a little. “I don’t think so.”

“Can you lean forward?” I said, giving him a little push.

He took two short breaths like a weightlifter in the clench and stayed right in place. “Not really,” he grunted.

When I was on my way into his room, the nurse had stopped me. There was a decision I had to make, the quicker the better. “MAP is sixty,” she said. “Want to give fluids?”

It took me more than a second to realize what she was saying. The mean arterial pressure tells us if our vital organs are receiving an adequate amount of blood and nourishment. If this number is too low, then organs aren’t receiving the blood supply needed to survive. My new patient’s MAP was right at the cutoff. Patients with low MAPs usually have to go to the ICU. Mr. Alvaro had just come from the ICU, and the nurse wanted to know if we could give IV fluids to bring up the MAP or if we needed to send him back.

I told the nurse to give me a minute. In thinking about what to do about the MAP, I had almost blinded myself to what was in front of me: a scared man, struggling to live as much as to die. I went back into the room, sat down beside Alvaro, and listened to his story.

Alvaro told me about the past nine months of his life—not about the pain or the vomiting or the bloody stools constantly filling the bag attached to what remained of his intestines, but how he had become a burden to his family. His daughter stayed with him in the hospital most nights and worked during the day cleaning offices. She had to. If you’re poor and people depend on you, you can’t not make money. She had kids at home too, school-aged kids. Alvaro told me she should have been taking care of them, not him.

Somehow, in this moment, my Spanish didn’t stumble. “You know that it’s okay if you die,” I said. As ever, I could hear a note of gringo, but the accent sounded muted, unimportant.

He was the same age as my grandfather; maybe that’s why I said what I did. Or maybe seeing the fear in his eyes when we discussed what might happen next, that this could go on, gave me the courage to be frank.

When I came out of the room, I saw the nurse talking with a woman I quickly recognized as Alvaro’s daughter. I buttoned my white coat and wove my way into the conversation.

“How is he?” the daughter asked.

I told her what Alvaro had told me, that he didn’t want doctors to resuscitate him if his heart stopped, that he didn’t want a breathing tube inserted under any circumstances. What this meant was that he wouldn’t be returning to the ICU again, ever.

“He’s been through so much,” I said in Spanish. “I think he’s tired.”

She nodded. It was still summer, the ridiculous Houston heat continued to broil outside, and yet everyone in Ben Taub wore layers and long sleeves. The AC did that to us. The daughter shivered, held her elbows tight. “I know he is,” she said.

As I started to walk away, the nurse reminded me about the MAP. “Are we giving fluids?”

“He’s DNR/DNI now,” I said. “I’ll put in the order.”

I flipped to the “Orders” section of his chart, wrote “Do Not Resuscitate” with my signature timed and dated, and slid the wobbly chart into its slot. I called my attending and told him about the change. Immediately I turned my attention to the next name on my list, a patient staying on the other side of the hospital. I didn’t walk there with my usual quick pace, but I didn’t saunter either. Ten minutes later, I was absorbed in a different patient’s chart. That’s when my pager went off. I cursed having to be so connected and called the number back.

“This is the intern,” I said.

“Just wanted to let you know that Mr. A just passed,” said the nurse.

“He’s dead?”

“The daughter’s at the bedside.”

I rushed back to the unit and met the daughter in the hallway. She was on the phone, pacing, crying, holding a tissue beneath her nose, getting words out. I didn’t want to interrupt her, and so I waited until I had her attention, and then I mouthed to her in Spanish, “Lo siento.”

She smiled at me courteously and held her hand over the receiver. “It’s okay, it’s really okay,” she said.

It didn’t hit me until after I performed what had to be done next—the death exam, the death note, signing off for Transportation to wheel the body away—that Mr. Alvaro might have still been alive if we hadn’t talked. Was that even possible? That words could mean the difference between life and death?

I knew the words I had written—“Do Not Resuscitate”—had that power, but what about our shared words? What about what I had said to Mr. Alvaro? What about what he had said to me? What about Mr. Alvaro’s story?

It’s been over a decade since Mr. Alvaro died. I’ve cared for hundreds of patients at Ben Taub in that time, patients from Nigeria, Bhutan, Eritrea, Vietnam, the Fifth Ward here in Houston, even from my grandparents’ village in El Salvador. I’m no longer an intern. In fact, now I am the one teaching residents and medical students. Still, I try to find my patients’ stories. It’s my favorite part of being a doctor. I don’t mean their medical histories. I mean the circumstances of their lives. All of this information helps me to better empathize with them, but the stories also make medical care more efficient, more personal, and they reduce the number of tests needed to diagnose and give treatment.

Hearing a patient’s story helps me visualize their illness. If, for instance, they tell me they drenched their bedsheets the past few nights and that they nearly passed out this morning while standing to use the bathroom, a vision of a dry creek appears in my mind. This is what the veins inside their body look like, I tell myself: a kidney infection, like a violent summer, has dehydrated them. The image of this illness helps me prioritize what medicines I prescribe: I know I need to write for IV fluids and antibiotics to replenish the creek immediately. Using metaphors like this has helped me understand how the body works.

This book uses stories to think through a problem that goes beyond any one body. It comes from a question formed, in part, by experiences like the one I had with Mr. Alvaro: Why do some people benefit from healthcare in America while others are excluded? The stories appear intertwined, each building on the others. Some take place before the COVID-19 pandemic and others during. I’ve pieced them together alongside some of my own personal stories in order to think about the basic foundations of our healthcare system in America and uncover for myself how Ben Taub illuminates what is missing in American medicine.

“There ought to be a man with a hammer behind the door of every happy man,” Anton Chekhov wrote, “to remind him by his constant knocks that there are unhappy people.” Many people know Chekhov worked as a doctor, even as he wrote his short stories and plays in late nineteenth-century Russia, but his devotion to the poor is not so well recognized. Chekhov traveled via horse-drawn carriage from Moscow, which sits on Israel’s longitude, three months through the Russian tundra, nearly four thousand miles, to Sakhalin Island, just north of Japan. He did this to write about the deplorable conditions of a penal colony on Sakhalin, as well as the public health failures.

More than anything, however, Chekhov wrote about the people living in these desperate conditions. As famous as he was, Chekhov could have worked as a concierge doctor and catered to Moscow’s elite. Instead, he wrote stories about the poor so that the fortunate might understand that their plight is everyone’s responsibility: “Apparently a happy man only feels so because the unhappy bear their burden in silence.”

Chekhov eventually died of tuberculosis, an illness he contracted from the patients he served. He had been born poor. His patients were poor. He had traveled to the poorest part of Russia. He saw in his practice how tuberculosis devastated his fellow Russians with a mortality rate of four hundred deaths per one hundred thousand people, one and a half times that of COVID-19 in the United States more than a century later. Chekhov also recognized how little the government of his beloved Russia cared about tuberculosis and poverty. The authorities had enacted a campaign they called the “Fight Against Tuberculosis,” which consisted of nothing more than epidemiological surveys. For all its pomp, the program received no funding from the state. Rather, it relied on charity.

This touched a nerve with Chekhov, and three months after returning from Sakhalin, he wrote a letter to the vice director of the Ministry of Justice, a man who taught law, served as a judge, and, it so happened, had a soft spot for writers. “I believe it is very harmful to have to depend mainly on charity,” he wrote. “I think it would be far better if this problem were to be addressed by funding from the state.”

Chekhov explained that the problems in Sakhalin went deeper than whatever numbers might appear on a survey: “I encountered no infectious diseases on Sakhalin, and found very little congenital syphilis. But I did see children who were blind, dirty, and covered in sores, all diseases that bear witness to neglect.”

Years later, at the height of his popularity, Chekhov sat down in the dining room of the Hermitage restaurant, one of the most exclusive locations in all of Russia. As the meal began, blood began to stream from his mouth. The tuberculosis—which up to that point had for him been more of an annoyance than a debilitating illness—had caused his lungs to hemorrhage.

He lay in bed for days recovering, first at a clinic and then at a hotel. The clinician and master of the written word received what treatments were available, including ventilated air spiked with turpentine and eucalyptus, wine from Hungary, a cognac after dinner. He wrote more letters in his convalescence, including to young authors, giving them advice. “Your task is to be a sincere artist writing only about what exists or what you think ought to exist,” he wrote, “painting pictures of life as it is.”

This book takes inspiration from the many letters Chekhov wrote as much as from his fiction. Chekhov never got to see his beloved Russia reform the way it treated its sick and poor. The scourge of tuberculosis continued until governments around the world recognized the illness as a public health threat and invested in institutions. Improved social conditions, measures to ensure the poor weren’t malnourished, and public education on the illness, as well as the end of World War I, helped cut the death rate from tuberculosis in half in Europe and Russia by the mid-1920s. Had he lived, Chekhov would’ve been in his sixties by this time. Instead, he died at age forty-four in a sanatorium in the Black Forest.

But his devotion to the poor and to his writing had meaning. The man at the Ministry of Justice to whom Chekhov had written took his words to heart. Russia’s criminal code was revised one year before Chekhov died, meaning that fewer people were sent to suffer on Sakhalin Island. As a patient and a doctor and a person who cared deeply about the suffering of others, he never would’ve chosen to have tuberculosis, but he also didn’t regret contracting it—or, at least, he never said he did in the letters he wrote. Even at the peak of his illness, in the throes of maximum symptomatology, he blamed and reviled no one, not even the patients who transmitted the disease to him. Connecting with people, serving them, making them think and enjoy life for the length of a play or short story, or even an appointment in his clinic, meant that much to him.

So did pushing to change the system that ignored this suffering. Histories were Chekhov’s hammer. The tapping on the door we hear in stories of injustice—his and all stories that depict the unhappy living in silence—should awaken us to find more humane ways, in this case, of providing healthcare.

The stories in this book are inspired by Chekhov’s portrayal of people hidden from us. But this book also shows what Chekhov didn’t live to see: more people working to alleviate this suffering, and government, not charity, helping in this work. It is a love letter to the hospital, my hospital, where people find healthcare and revere it like treasure. It is also a letter to those sitting in positions of authority, to alert them to the consequences of failing to act with immediacy. As Chekhov himself noted, when we hear the hammer tapping upon our door, we should spring up:

“In the name of what must we wait?”

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