Our Malady: Lessons in Liberty from a Hospital Diary

by Timothy Snyder

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.

Solitude vs. solidarity theme.

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. This also held for the counties in Ohio that Barack Obama had won and Mr. Trump took four years later: all but one of them was in opioid crisis. Votes of desperation, like deaths of desperation, are understandable. Yet those who remain behind suffer. Desperate voters close off care to themselves, their families, and everyone else by voting for politicians who traffic in pain.

Interesting otes on opiod abuse and being shut off from yourselfand desperate votes for Trump.

A solitary rage is part of freedom, but only part. If we have no help from others, our rage no longer protects us but endangers everyone. Once pride becomes resentment, we forget that we need help and claim that only others do.

Mass violence?

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.

Politicians taking advantage of pain.

Flattering while denying care adds sadism to manslaughter.

Note on flattery movinf to sadism...

Between the choice to live in pain and the choice to take pills, there should be a world of alternatives: health care that we can find, or that can find us. This

Alternatives between pain and pills.

We need a system of solidarity that no individual can create but from which every individual would gain.

Theme of solidardity over solitude again.

These beliefs prevent us from challenging a system of commercial medicine that treats us as sources of profit rather than as children of God.

Amen! Humans as profit centers instead of children of God.

It is also tempting to rest on the laurels of tradition, to refer back to the eighteenth century, to say that the Founding Fathers did not imagine modern public health. There are many things, of course, that they did not imagine. 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.

What might tfhe Founding Fathers really have wanted.

Jefferson thought that health was the most important element of a good life, after morality.

Jefferson's thoughts on health.

Now that we have better knowledge of the natural world, 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. If we have a right to pursue happiness, then we have a right to the care that allows us to do so. Without health, said Jefferson very sensibly, there is no happiness.

right to health would have been accepted by the Founding Fathers.

In the United States one has to have good insurance or spare cash to see a lactation consultant, and most people do not. In this way, inequality affects the biology of babies from their first hours. It does no honor to the idea that “all men are created equal” to mandate an unequal start of life.

Money driving all again...

This attitude to parents and young children is certainly not a result of Austrians being friendlier than Americans. It has to do with an understanding that rearing children is not something that a parent or even a family can do without help. The institutions that helped us, from the public hospital to the public kindergarten to the public transport (with an elevator at every subway stop), were not one-way gifts to families with children. They were an infrastructure of solidarity that held people together, making them feel that at the end of the day they were not alone.

It takes a village.

It takes courage for adults to grasp this, because it means that caring about freedom means caring about children.

Caring for children is bases for freedom.

The paradox of freedom is that no one is free without help. Freedom might be solitary, but freedom requires solidarity.

Solidarity thsems again...

This is how tyranny works: the truth tellers are banished as the sycophants huddle close. Mr. Trump then wondered aloud whether Americans should inject themselves with disinfectants.

How truth gets lost.

Once Mr. Trump made it clear that his priority was to see low counts of infected Americans, the simplest way to please the tyrant was not to count.

Lows counts equal no counts.

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 this case the reality of an epidemic that would kill more Americans than any in the past hundred years. It was delusive because it confused looking away with taking action, the absence of testing with the absence of infection. Mr. Trump’s unwillingness to test did not mean that we were healthy, only that we were ignorant. It was irresponsible because it transferred accountability for American lives away from himself and our government. 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.

Tyranny through delusion, ignorance and blame.

In the United States, we have both the highest death toll from coronavirus in the world (authoritarian disregard for life) and the certainty that it is a severe undercount (authoritarian resistance to facts).

Authoritarian disregard for life AND authoritarian disregard for facts.

Big data is generally about how your mind can be manipulated for profit, rather than how your body might better move through the world. It can reveal our particular cravings and fears, but not our common needs.

Failings of big data.

No social platform can improve health, since any algorithm with such a goal would alert people to shut down their computers, wash their hands, and get some exercise. No social platform can promote freedom, since social platforms aim at addiction. No social platform can promote truth, because truth, as Euripides realized twenty-five hundred years ago, is about human daring. We care about free speech not because a machine can dump endless garbage into the maw of our worst instincts, but because an individual human being can say something true that others do not know and that power wants hidden.

Failings of social platforms.

Where social media has extinguished local journalism, distrust and ignorance reign.

Lack of local journalism leads to distrust and ignorance.

This is an example of the paradox of liberty: we cannot be ourselves without help; we cannot thrive in solitude without the solidarity of others. We can only balance solitude with solidarity when we share a factual world that enables us to see the larger meaning of our actions.

Paradox of liberty.

If patients understood how enserfed doctors have become, they would be less likely to come to hospitals, and less money would be made. American doctors are becoming props in advertisements, the front men and women whose coached smiles are meant to cover the gaps in our ragged patchwork of competing hospitals.

American medicine...prop doctors with no authority. Enserfed!

The pandemic was a moment when the cover dropped, when we could see that doctors do not matter in society and politics. 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 it. The richest zip code in America was granted two million dollars for no very clear reason. Insurance companies and private equity firms had a voice in policy; physicians and patients had none.

Medical corruption along with political corruption.

Doctors in South Korea looked like they were coming from a science fiction movie; ours looked like they were coming from the Salvation Army.

South Korean medicine vs. US medicine!

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.

Commercial medicine...

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.

...profitable sickness.

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. But they make money.

Implants...big profit cesnters which are totally unregulated.

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.”

Doctor's notes being co-opted for billing instead of medical.stuff.

As Benjamin Franklin wrote in another context, “the Malady consists in the enormous Salaries, Emoluments, & Patronage of great Offices.”

Franklin's quote about Malady.

No amount of propaganda can blur the basic fact about American commercial medicine: we pay a huge premium for the privilege of dying younger.

Americans pay a huge premium to die younger!

Most of the insurance industry simply collects rents from disease, like trolls on a bridge demanding a toll. The trolls’ profits misleadingly count in gross national product, though they are supplying no good and performing no service. Economic logic says that the middleman should be removed when possible, and we know how it is possible in this case: with a single-payer system at the center of things, and private insurance at the margins. Countries where people live longer have shown that this works. Thousands of doctors have made the case for it. If we all cross the bridge to health together, the trolls cannot stop us.

Medical industry collects rent on our ilnesses.

The most influential of the market economists, Friedrich Hayek, opposed oligopoly, or ownership by a few, which he compared to Soviet central planning. Our medical-industrial complex is a set of oligopolies. Our big data industry is also a set of oligopolies. Hayek is right: they should be broken up. In his most famous work, The Road to Serfdom, Hayek worried about a “dispossessed middle class,” which commercial medicine is now creating. He took for granted that in civilized countries everyone would have access to care: “The case for the state’s helping to organize a comprehensive system of social insurance,” as he wrote, “is very strong.” He knew that “there is no contradiction between the state’s providing greater security in this way and the preservation of individual freedom.”

Hayek took for granted medical care for everybody as a means for economic freedom.

What we take for granted can change quickly and for the better. It can also change quickly and for the worse. Now we choose. It is easy to give money to the wrong people during a pandemic, and easy to give away freedom at any time. It takes work to be free, and courage to see opportunity. This crisis is a chance to rethink the possible. Health care should be a right, doctors should have authority, truth should be pursued, children should see a better America. Let us begin our recovery.

Easy to give away...hard to maintain it.

History is never entirely behind us.

History is never entirely behind us.

Health is our common vulnerability, and our shared chance to grow freer together. Healing our malady would enrich life, extend liberty, and allow us to pursue happiness, alone and together, in solitude and in solidarity. To be free we need our health, and for our health we need one another.

Freedom and health...one in the same.