Our Malady: Lessons in Liberty from a Hospital Diary

by Timothy Snyder

The rage was pure me, my wish to be a sound not an echo, to compose not decompose. It was not against anything, except the entire universe and its laws of unlife. For a night or two I could shine in my own light. Yet, slowly and softly, a second mood impinged, one that sustained me in a different way: a feeling that life was only truly life insofar as it was not only about me. Like the rage, this mood visited me when I was alone, when I could do little for myself, when my whole sense of motion came from visions in my mind. In this mood I felt myself to be in a cluster of something with other people, tumbling through time. When I tried to draw the feeling in my journal, I came up with an uneven, floating conveyance. It looked a bit like a raft. A raft can be built over time from bits and pieces. I was a part of a raft, and others were, too; we were floating and jostling together in the same water, sometimes effortlessly, sometimes against the rocks. If my plank fell into the deep, the raft might lose its way or capsize. Some planks of the raft were further from mine, and some were closer. I recited to myself the ways my children’s lives were bound to my own. What mattered was not that I was distinct, but that I was theirs: their father. Every bit of their existence involved the expectation of my presence. They had never not touched me. Their planks had always been bound to mine. I imagined what would change without me, beginning with the daily details that mark the mental c...

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. We would like to think we have health care that incidentally involves some wealth transfer; what we actually have is wealth transfer that incidentally involves some health care. 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 malady is particular to America. We die younger than people in twenty-three European countries; we die younger than people in Asia (Japan, South Korea, Hong Kong, Singapore, Israel, Lebanon); we die younger than people in our own hemisphere (Barbados, Costa Rica, Chile); we die younger than people in other countries with histories of British settlement (Canada, Australia, New Zealand). Other places keep passing us in the longevity charts. In 1980, when I was ten, Americans lived on average about a year less than inhabitants of countries of comparable wealth. By 2020, when I was fifty, the difference in life expectancy had grown to four years. It is not that other countri...

I was tested, slowly, for flu, for this and that, with little result. I had undergone my appendectomy in the same hospital two weeks earlier, but no one in the emergency department seemed inclined to look at my electronic record. I had brought a folder with the printouts and a CD from the Florida hospital, and I had just enough presence of mind to offer it to the doctors. They were not interested. “We do things our own way,” said the resident. The doctors and nurses seemed unable to complete a sentence, let alone think about my case as something with a history. I could see, or rather hear, why they were distracted. The familiar sounds from beyond the curtain drew my attention as well, even as my vital signs worsened and the infection spread through my blood. An alcoholic beyond the curtain to the right, an older lady from the sound of her voice, kept crying out “Doctor!” or “Nurse!” A second alcoholic, to the left, was a loquacious homeless man. When asked for his belt, he riffed on the idea of the “Belt of Orion,” comparing himself to the hunter and rapist of Greek mythology. Whenever approached by a female doctor or nurse, he said, “You belong to me; don’t try to fight it.” One of the nurses declared that she didn’t belong to anyone. When he was discharged, he was asked the standard questions about whether he felt safe at home. This was absurd, since he had no home and was going back out into the cold. It was also obscene, since his answers to the questions involved the ...

If we think that the Nazi Holocaust is the depth of malevolence, what then is the height of good? If we decry Hitler’s language and actions, what follows for what we ourselves say and do? 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. Another shelf of books in my office is dedicated to studies of concentration camps. 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. Stalin’s Gulag was run according to this logic of reverse health care. Because Soviet administrators regarded prisoners as economic units, health care was distributed according to calculations about productivity. Medical attention meant figuring out who could be exploited for longer and who should be discarded sooner. Stronger prisoners might be cared for so long as they were productive, but weaker ones were allowed to die, often released from the camp to perish beyond its gates—so as not to be counted, so as not to figure in the record. If we think that the Gulag is the depth of horror, what then is the su...

My wife turned forty during her second pregnancy, which triggered an American protocol for labor to be artificially induced by her due date. These protocols make little sense: it’s not age as such that matters, but certain conditions that become more likely in women with age. In large matters and small, machine protocols get between patients and their caretakers. The computer programs are about billing, and so fail to account for basic human needs. Doctors and nurses who get used to following protocols retrain themselves to ignore the actual patient. When I was in the hospital I noted some examples of this in my diary. I took medications on a schedule. I wrote down the times and doses, partly because I had lost trust in the system, partly because I wanted to sleep at night. I was allowed to take acetaminophen every six hours for pain. I would ask the nurses not to wake me at night simply because six hours had passed. Sometimes this worked; sometimes it didn’t. When I would skip a dose, I would try to explain that the schedule should reset, and that my next dose could be at any time, rather than six hours after the scheduled time for the dose that I had not taken. Sometimes nurses went along with me, sometimes with the screen. I might in the evening have three medications to take, one at 10:00, one at 11:00, and one at midnight. A savvy and motivated nurse would alter the timing of the doses during the day so that, after a couple of days of nudging, I could take all three p...

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. Every day, physicians have to pretend to patients that they matter more than they do. 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.

To understand the shortage of beds, it helps to think of just-in-time delivery. Companies like to have just enough space for what they need, work with, and sell, not more and not less. For a hospital, the human body is the object that is to be delivered, altered, and shipped away just in time. There should never be too many bodies, or too few bodies. There should be just the right number of bodies on just the right number of beds. Good doctors, good nurses, and good assistants resist this logic all the time, but they are pushing a boulder up a mountain. Maintaining beds costs money. No hospital, in American commercial medicine, is going to maintain a reserve of beds when other hospitals do not do so. Since financial logic dominates medical logic, the country must always be unprepared for epidemics. There can never be a reserve of beds, nor for that matter a reserve of protective equipment or ventilators. Managers counting on a quarterly profit cannot factor in pandemics, which arrive about once a decade. Each time a plague comes, the situation will be defined as exceptional, and the shortages will make the emergency even worse than it had to be. Then money will fly around: not to where the doctors might want, since they will not be asked, but to the sectors of the economy with the loudest voices. This just happened, and with commercial medicine it will keep happening. In the hospital, sad to say, a body is a widget. Kindly assistants, competent nurses, and decent physician...

As computer programs determine how many patients can be profitably squeezed into a day, doctors become tools. Then the actual machines march triumphantly into the wards. Nurses are now separated from patients by computers on wheels that roll everywhere with them: their bossy robot taskmasters. When you first see a nurse, she or he will likely have eyes on the screen rather than on you. This has dreadful consequences for your treatment, since you become a checklist rather than a person. If you are having a problem unrelated to what is on the screen, some nurses will have a hard time gathering themselves and paying attention. For example, after my first liver procedure my liver drain was improperly attached. This was a serious problem that was easily reparable. Yet although I tried for four days to draw attention to it, I could not get through. It was not on the lists. And so I had a second liver procedure. When I read my own medical record, I was struck by how often doctors wrote what was convenient rather than what was true. It’s hard to blame them: they are locked in a terrible record-keeping system that sucks away their time and our money. When doctors enter their records, their hands are guided by the possible entries in the digital system, which are arranged to maximize revenue. The electronic medical record offers none of the research benefits that we might expect from its name; it is electronic in the same sense that a credit card reader or an ATM is electronic. It i...

We should regard health care as a right, take medical and local knowledge seriously, make time for young children, and put doctors in charge. The realization of these lessons will cost some money now—and save far, far more in the years to come. The question is not how much this would cost. The question is how enormous the gains would be. 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. 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. A market economy such as ours works better when people are cared for. If it is liberty that we want, then we do not sacrifice human freedom to market dogma, but rather make markets work for freedom. The most influential of the market economists, Friedrich Hayek, oppose...