Our Malady: Lessons in Liberty from a Hospital Diary

by Timothy Snyder

Unless something changes, millennials will live shorter lives while spending more money on health care than Gen-X parents or boomer grandparents.

Middle-aged white men are committing suicide and drugging themselves to death in astonishing numbers.

Our system of commercial medicine, dominated by private insurance, regional groups of private hospitals, and other powerful interests, looks more and more like a numbers racket.

Freedom is about each of us, and yet none of us is free without help. Individual rights require common effort. The Declaration of Independence posits that “all men are created equal,” and closes with the willingness of all of its signatories to defend that principle. A right is something that we are convinced we deserve, but it only becomes real in the world when forced upon the powers that be.

Something in me hesitated over the story of a woman whose special gift, as she hid Jews in her apartment, was to behave as if nothing extraordinary were taking place. Poise. Existential poise.

The doctors and nurses could not spend more than a few seconds at a time with me, and rarely made eye contact. They ran their blood work, forgot the results, misreported them, ran off. 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.

People are much poorer at almost every task when they are close to a cell phone; both physicians had kept theirs turned on and close by.

Like everything that happened, this wasn’t my bad luck. It is the nature of the system that doctors are harried and make mistakes.

If some Americans have access to health care thanks to wealth or connections, they will feel pleased because they are included and others are not. Such a feeling turns our human concern about health into a silent yet profound inequality that undermines democracy. 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 is a privilege rather than a right, it demoralizes those who get it and kills those who do not.

If health care were a right, we would all have better access to treatment, and would all be liberated from the collective of pain. Health care should be a right, not a privilege, for the sake of our bodies, and for the sake of our souls.

The Nazis treated health care as a way to divide the humans from the subhumans

and nonhumans. If we see others as bearers of ailments and ourselves as healthy victims, we are little better than they. If we truly oppose the Nazi evil, we will try to think our way to its opposite, to the good. A part of that effort is to understand that all humans are subject to malady, and have an equal claim to care.

Usually those who run concentration camps treat healthier people better and sicker people worse. When concern for human dignity and human life is absent, all that matters is the labor that can be extracted.

Most nations’ constitutions enshrine a right to health care. The list includes Japan and Germany, whose new constitutions the United States influenced after defeating them in the Second World War. Today Germans and Japanese live longer and healthier lives than Americans.

My tolerance of pain comes from the same place as the rage that saved my life. It has helped me to do work that I value. Yet enduring pain in silence also creates a vulnerability, one that I think I share with other Americans. No one can endure extreme pain indefinitely. If there is a pill, we will all one day take the pill. If there is no one to talk to, no other form of medical care, we will keep taking the pill.

I wanted them to just write me a prescription and let me go. Yet the European doctors liked to talk to me about the kind of life that I led, not just about the triggers of the migraines, but also about my priorities and practices.

The French, Austrians, and Germans have the same medicines we do—and they are less expensive and easier to get. In Germany I can get migraine medication without a prescription for a couple of euro at any pharmacy, even at an airport or railway station, provided that I take a moment to explain to the pharmacist why I need it. Every single part of that is impossible here. The difference is not that we have fancy chemicals and the Europeans do not. The difference is that doctors in Europe have time to do something beyond write out prescriptions.

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.

Everyone is drawn into a politics of pain that leads to mass death. Opposing health

care because you suspect it helps the undeserving is like pushing someone else off a cliff and then jumping yourself, thinking that your fall will be cushioned by the corpse of the person you murdered. It is like playing a round of Russian roulette in which you load one bullet in the cylinder of your revolver and two in the other fellow’s. But how about not jumping off cliffs; how about not playing Russian roulette? How about we live and let live, and all live longer and better?

is important to acknowledge how policy changes practices, and how practices change norms. Thanks to parental leave, walking around with babies was a normal thing for men to be doing. It was nice to occasionally share a nod of acknowledgment with other guys: hey, what a great thing, we are dads.

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.

China does bear responsibility for ignoring the reality of the outbreak. Yet American policy was to repeat China’s mistakes, after China had made them, and for a far longer time. For that only Americans can be blamed.

Mr. Trump opined that the problem with unimpeded voting is that “you’d never have a Republican elected in this country again.” He decried voting by mail, although he himself votes by mail.

Mr. Trump’s behaviors followed the authoritarian pattern: a denial of reality, the claim of magical immunity, the harassment of reporters, the transformation of a problem he caused into a loyalty test for others, the cultivation of fear as a political resource. Authoritarians will allow people to die uncounted rather than admit that the number of dead in their country was high.

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.

If there are no local reporters, no one follows up on health complaints, or tests the water and air.

A second example of how news deserts kill is the opioid crisis, which coincided with the collapse of local news. Americans in places like eastern Kentucky, western Pennsylvania, West Virginia, and southern Ohio knew, long before opioids made headlines, that something ominous had people in its grip.

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

In 2020, the lack of local reporters had the same consequence for the coronavirus as it had for pollution and opioids. We were missing the people whose work would have clarified a national disaster.

Conspiracy theories spread because social media had taken the place of local newspapers. Propaganda from Russia or China had easier access to dinner table conversation than realities down the block.

The problem is not that doctors do not want to work with patients. As we see during the coronavirus pandemic, physicians can work extraordinarily hard and risk their own lives trying to save the lives of others. The problem is that doctors have very little say in what happens around them, and waste their time and energy pacifying greater powers. They no longer have the authority that patients expect and need.

The coronavirus was a financial bonanza for people with unrelated economic interests, such as owners of commercial real estate. The floodgates were opened for firms working for the Trump presidential campaign and companies whose owners donated to

Insurance companies and private equity firms had a voice in policy; physicians and patients had none.

Our federal government managed to spend two trillion dollars without purchasing what we actually needed: tests, masks, gowns, and ventilators. Into early March it was actually the policy of the Trump administration to export masks made in this country to China. Not a single shipment of medical-grade N95 masks arrived on American shores in March 2020.

Mr. Trump’s comparison to war was flawed, since it made his authoritarian incompetence seem like the result of some unexpected enemy attack. But if this is a war, it is one where the commander in chief ignored every warning and then sent troops to the front line without weapons and body armor. It is a war whose soldiers have no

right to speak about what they saw; a war not of a silent generation, but of a silenced generation. It is a war that took more American lives than any since the Second World War—and even that could change.

The reason why there are never excess beds, the reason why Americans who have appendectomies go home too soon, the reason why mothers are expelled prematurely from maternity wards, is that we have commercial medicine. The fundamental calculation is financial.

Health and life are human values, not financial ones; an unregulated market in the treatment of our bodies generates profitable sickness rather than human thriving.

In the United States, implants are essentially unregulated. We do not keep a register of which objects are in which bodies. Because legal standards are as lax as regulatory ones, we do not even learn from lawsuits about suffering and death caused by implants going wrong. It is likely that implants are one of the leading causes of death in the United States, perhaps even the single leading cause.

As one doctor explained, “Notes are used to bill, determine level of service, and document it rather than their intended purpose, which was to convey our observations, assessment, and plan. Our important work has been co-opted by billing.”

Young people go to medical school for good reasons, then find their sense of mission exploited by their bosses. Pressured to see as many patients as possible, they come to feel like cogs in a machine.

Tormented by electronic records that take as much time as patient care, and tortured by mandatory cell phones that draw them away from thinking, they lose their ability to concentrate and communicate. When doctors are disempowered, we do not learn what we need to be healthy and free.

Doctors should work from thousands of small offices around the country, or even make house calls. Why does easy contact with a physician seem like a dream?

Whether a hospital was adequately staffed during the coronavirus pandemic had to do with national balance sheets, not local needs. None of this has anything to do with the basic labor of being a doctor.

We need a health care system that begins where people live, rather than expecting them to know everything themselves, or to master complicated paperwork, or to pay hidden fees.

About 120 hospitals have closed in rural America in the past decade. Two of them shut their doors in March 2020, during the pandemic. Americans in rural counties without hospitals were more likely to die once infected. The first person known to have died of a novel coronavirus infection in West Virginia had just lost her local hospital.

Specialists make more money than generalists, and young American doctors usually have debt. As a result, too few decide to become pediatricians and internists. The entire field of geriatrics, care for the old, is disappearing.