Our Malady: Lessons in Liberty from a Hospital Diary

by Timothy Snyder

Recently I have been thinking and speaking about how history defends against tyranny in the present and safeguards freedom for the future.

It was easy to grasp that freedom and health were connected when my will could not move my body, or when my body was attached to bags and tubes.

I raged therefore I was. The rage cast a light that revealed an outline of me. “The shadow of the solitary is the unique,” I wrote, rather obscurely, in my diary.

The beginning of life in this country is frightening and uncertain. Care of expectant mothers is wildly uneven and grossly inadequate. Black women often die in childbirth, and so do their babies. The mortality rate of babies borne by African American women is higher than in Albania, Kazakhstan, China, and about seventy other countries.

If birth is not safe, and is less safe for some than for others, then something is wrong. If more money is extracted from young adults for health care, but they are less well than older generations, something is wrong. If the people who used to believe in the country are killing themselves, something is wrong. The purpose of medicine is not to squeeze maximum profits from sick bodies during short lives, but to enable health and freedom during long ones.

Our botching of a pandemic is the latest symptom of our malady, of a politics that deals out pain and death rather than security and health, profit for a few rather than prosperity for the many.

“The whole history of the progress of human liberty,” as Frederick Douglass reminds us, “shows that all concessions yet made to her august claims have been born of earnest struggle.” It will be a struggle to heal our malady. The struggle begins when we claim health care as a human right.

The permanent distraction of doctors and nurses is a symptom of our malady. Each patient has a story, but no one is following the story.

When everyone has access to decent care at minimal cost, as is true for almost all of the developed world, it is easier to see fellow citizens as equal.

If health care were available to everyone, we would be not only healthier physically but also healthier mentally. Our lives would be less anxious and lonely because we would not be thinking that our survival depended on our relative economic and social position. We would be profoundly more free.

The constitution of the World Health Organization, founded in 1946, states: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The Universal Declaration of Human Rights of 1948 states: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

In our country, where pharmaceutical advertisements are the main source of health information, we keep learning the lesson that suffering is our personal responsibility and that pills are the cure. When painkillers work, that creates a particular danger, because then we can ignore the deeper sources of suffering. We then get in trouble when we increase the dose, or find that medicine no longer works. Suffering and self-medicating are both lonely activities; they can feel like free choices, but they create an imbalance that leaves us in bondage.

“Right to work” propaganda teaches Americans that we should go it alone, without unions, which leads to worse jobs, fewer friendships, more racism, poorer health care, and more anger.

White women in the South are living shorter lives, in part for this reason. The life expectancy of middle-aged white males has stagnated. Their American dream of solitary self-sacrifice has failed, and without the solidarity once offered by unions and the welfare state, they have been left alone with their resentment. If all we have is lonely rage, we fail, become addicted, listen to the wrong people, harm those we care about, and die.

People who lived in places wracked by opioids voted for Donald Trump. The one piece of information that best predicts whether Mr. Trump won or lost a county in November 2016 was the degree of opioid abuse. In Scioto County, ground zero of the opioid epidemic, Mr. Trump took a third more votes in 2016 than Mitt Romney had in 2012. It was a surprise when Donald Trump won Pennsylvania. He got the majority of votes in several Pennsylvania counties that Barack Obama had won four years before. Every single one of those counties was in public health crisis as a result of opioid abuse.

Desperate voters close off care to themselves, their families, and everyone else by voting for politicians who traffic in pain.

Once pride becomes resentment, we forget that we need help and claim that only others do. A fury that lashes out blindly is no mark of liberty, but an opportunity for politicians who provide targets for the anger. The downward spiral from pain to desperation and from pride to resentment is something that politicians like Mr. Trump understand and accelerate. They want people staggered by suffering, and so they oppose health care. Pain is their politics; their propaganda is a death trap.

When someone dies we can tell ourselves that it had to be so, that it happened for a reason, that it was God’s will. These beliefs prevent us from challenging a system of commercial medicine that treats us as sources of profit rather than as children of God.

It is impossible for me to believe, as a citizen and as a historian, that the Founding Fathers wanted an America where people would live shorter and worse lives than necessary, where the sickness of the many would become a zone of profit for the few. The optimism in the preamble of the Constitution rings down the centuries: good government means justice, tranquility, welfare, liberty. A common defense. If we take pride in our Constitution and know its purposes, we apply the aspirations of its authors to our own times.

we can consider health care as a human right. The Constitution does not prevent us from doing so. On the contrary: its authors had the wisdom to specify that “the enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.” This leaves room for a right to health care. If we accept Jefferson’s famous trio of rights to “life, liberty, and the pursuit of happiness,” the case for a right to health care is made. If we have a right to life, we have a right to the means of living.

The paradox of freedom is that no one is free without help. Freedom might be solitary, but freedom requires solidarity. An adult who has learned to be free in solitude benefited from solidarity as a child. Freedom is thus a loan paid out and paid back over generations. Children need intense and thoughtful attention during those first five years. This special time cannot be given by children to children, nor by adults to adults. Children can only borrow this special kind of time from adults. They can pay back the loan only later, when they themselves are grown, to the children who are yet to come. A free country thrives over generations.

In early 2020, our federal government failed us in both ways. There was no sensible discussion of the history of pandemics, and no procedure to test for the new plague. In January, it failed to do what was so obviously necessary: acquire a test for the new coronavirus and apply it on a massive scale in the United States. The president’s administration had disbanded the sections of the National Security Council and the Department of Homeland Security meant to deal with epidemics, as well as a special unit in the Agency for International Development that was meant to predict them. American health experts had been withdrawn from the rest of the world. The last officer of the Centers for Disease Control and Prevention assigned to China was called back to the United States in July 2019, a few months before the epidemic began.

On February 1st, the surgeon general of the United States tweeted “Roses are red / Violets are blue / Risk is low for #coronavirus / But high for the flu.”

On January 24th, he praised China for its response to the coronavirus: “China has been working very hard to contain the Coronavirus. The United States greatly appreciates their efforts and transparency. It will all work out well. In particular, on behalf of the American People, I want to thank President Xi!” On February 7th, he renewed his praise: “Great discipline is taking place in China, as President Xi strongly leads what will be a very successful operation.”

When Americans known to be infected were evacuated from a cruise ship in February, they were flown back to the United States on an airplane with hundreds of other people who were not yet infected. The people infected en route then scattered freely throughout the country. This indefensible sloppiness by the federal government guaranteed that the disease would spread.

Since the truth sets you free, the people who oppress you resist the truth. In any catastrophe, especially one of their own making, tyrants will find a mixture of blaming others and excusing themselves that includes an enticing element of what we want to hear.

we cannot be free and deluded. History remembers the British prime minister Neville Chamberlain unkindly because he told his people what they wanted to hear in 1938: that there need be no war. History remembers Winston Churchill kindly because he told the British what they needed to hear: that Hitler had to be stopped.

The truth takes work. Facts do not often line up with what we believe, want to believe, or are led to believe. Facts are what we apprehend when we place ourselves at the right distance between our emotions and the world around us.

Such magical thinking was tyrannical, delusive, and irresponsible. It was tyrannical, in Plato’s sense of the word, because it revealed the tyrant’s narcissistic concern for his own image (“the numbers”) over the reality lived by others—in

As Mr. Trump denied any “fault,” the disease was spreading in our country, unobserved and untreated. His focus on a foreign source of “fault” meant that no one here was to blame. When no one bears responsibility, no one has to do anything.

Once politicians embrace ignorance and death, their next move is to bluster and blame. Journalists who ask the right questions and local leaders who act to save lives must be ostracized, because they reveal authoritarians as cowards.

The combination of free speaking and free voting allows citizens to report what their rulers are doing, and to replace the ones who lie about matters of life and death. When democracy is limited, citizens die. One of the limits on our democracy is the vast and unregulated presence of money in politics, which means that in times of crisis private equity firms and insurance companies get more of a voice in matters of life and death than patients and doctors.

Most American counties no longer have a proper newspaper. First, media was centralized in larger groups. Then the financial crisis of 2007–08 destroyed the livelihood of many reporters. Since then, the rise of social media has just about finished the job. Facebook and Google take the advertising revenue that newspapers once shared, though Facebook and Google do not report news.

Where social media has extinguished local journalism, distrust and ignorance reign. It is not simply that the facts are absent; it is that social media spread wild falsehoods,

As local journalism fades, American attention shifts to national stories, ideology, and conspiracy theories designed to do harm. Most of our country is now a news desert. News deserts kill us by depriving us of the information we need in our daily lives, and by leaving us confused at crucial moments when we need to act to protect our health and freedom. A familiar example is pollution. In the absence of local reporters, no one checks for unseemly relationships between politicians and companies.

A second example of how news deserts kill is the opioid crisis, which coincided with the collapse of local news.

With too few local reporters writing about overdose, it took a decade for a national picture of the disaster to emerge.

The death of truth brings the death of people, since health depends upon knowledge. The death of truth also brings the death of democracy, since the people can rule only when they have the facts they need to defend themselves from power.

We cannot be free without health, and we cannot be healthy without knowledge.

Health care that is too expensive is health care that does not work. Nearly half of Americans avoid medical treatment because they cannot pay for it. Tens of millions of Americans remain uninsured, and tens of millions more have insurance that is inadequate. I had decent health insurance, but still had to pay thousands of dollars in unexpected fees.

During the coronavirus epidemic, tens of millions of Americans lost their insurance because they lost their jobs. All Americans then suffered because the unemployed were left behind. Since they were undiagnosed they spread the disease, and since they were untreated they suffered and died. Because we offer appallingly little sick leave everyone in the country was put at risk.

When money becomes the only goal, values disappear, and people imitate the oligarchs. We do this now when we admire oligarchs’ fantasies of immortality rather than ask why our own lives must be shortened. When we indulge the daydreams of the ultra-wealthy, we create what Plato called “a city of the rich” and “a city of the poor.” When we turn a public health crisis into a bonanza for billionaires, we deepen our malady.

Robust public health lowers medical costs and reduces the risk of pandemics that destroy the economy. Investing in childhood means less mental and physical illness down the road, less prison time, fewer broken lives. It means more wealth for those who retire.

History is never entirely behind us. We can learn from the aspirations and failures of previous selves and previous eras, and create something new. I will not again be as I was before, nor do I wish to be; I have learned, and so I am better.