Our Malady: Lessons in Liberty from a Hospital Diary

by Timothy Snyder

This floating recognition that my life was not my own, this gentle empathy, escorted me away from death. This sense that life was shared began with my children but extended outwards, an uneven collection of timber making up the raft. I was splashing and tugging forward with everyone I knew and loved, and all would be affected if I fell away now. In this mood I was not raging, but floating along, remembering, contemplating, empathizing. The rage helped me see myself, helped my body and mind take on distinct form after a shock. The empathy placed me among others. In this mood, it was not so important that I was special. It was important that I was inside other people, in their memories and expectations, a support in the shape of their lives, a buoy during difficult passages. Since my life was not just my own, then my death was not just my own. When I reached that point, I began to rage again. This could not happen.

Part of our malady is that there is nothing in our country, not even life and not even death, where we take the proposition that “all men are created equal” seriously. 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. Since health is so elemental to existence, confidence about care is an important part of freedom. If everyone can assume that treatment will be available when necessary, they can turn their minds and their resources to other matters, make freer choices, pursue greater happiness. If, on the other hand, people think that care is preferential, then those who are on the inside start to take pleasure from the suffering of those who are on the outside. If health care is a privilege rather than a right, it demoralizes those who get it and kills those who do not. Everyone is drawn into a sadistic system that comes to seem natural. Rather than pursuing happiness as individuals, we together create a collective of pain.

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. I have come to admire doctors who actually have a moment, want to think together with their patients, and seem to care. And I have come to realize that they are working within a system that enables and encourages all of that. And that such systems not only work better but also cost less than our own. All of this care beyond our country, which I am very fortunate to have had, helps me to understand that there are alternatives beyond pills and pain. It is possible, if the appointments last longer than fifteen minutes and the doctors look at the person rather than the screen, for a patient’s story to be told and understood. Medication is important, but it has its limits.

When there is no one with time to talk, no chance to find another approach, then we come to feel that we have to choose between pain and pills. 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. American men slip from denying pain to denying that they have a problem with painkillers. They slip from facing everything down, not taking the pill, to giving everything up, and just taking the pill. If life is lived between pain and pills, we end up with too much rage and not enough empathy, too much solitude and not enough solidarity.

The welfare state, meant to complement the solitude of ambition with the solidarity of support, has been taken apart. On farms and in factories, physical toughness had measurable payouts. Suffering was part of productivity. Facing things down could be the right thing to do. Until the 1980s, American fathers who worked hard could expect better life chances for their children. That is no longer true. When the economy changed and the welfare state weakened, when pain lost its purpose and suffering its efficacy, men were understandably confused. Americans perform less physical labor now and report more physical pain. Sadly, pain has become part of the economy, and of our political system. It used to be that American politicians competed with visions of a brighter future. Now a good deal of our politics is the solicitation and manipulation of pain.

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. Opioids take over the mental space we need to contemplate, to think about children, spouses, friends, or anyone else.

The double desperation of pain and addiction affects our politics. 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. 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.

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. Such politicians tell white people that they are too proud and upstanding to need insurance and public health, which, they say, would only be exploited by others less deserving (blacks, immigrants, Muslims). Flattery lubricates the downward slide to death: white Americans are told to face pain as solitary individuals, and that they betray themselves and their country if they admit that they need support. Only dark-skinned whiners, goes the story, ask for help. Of course, the elected representatives who say such things have their own health care provided by the government, and are denying something to their constituents that they know works for them. But hypocrisy is the least of their sins. Flattering while denying care adds sadism to manslaughter.

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.

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. The right to liberty implies a right to health care. We are not free when we are sick. And when we are in pain, or when we are anxious about illness to come, rulers seize upon our suffering, lie to us, and strip away our other freedoms.

Their expressions turned to horror when I told them about the norm of parental leave in the United States. The idea that mothers might have twelve weeks but might have nothing, and that fathers expected nothing, seemed barbaric. They were right. It is barbaric. And it makes parents and children less free. As they pointed out, and as I was ashamed to realize, my notion that three months of parental leave for one partner was generous depended wholly on my knowledge that what my wife had was better than what other Americans had. My own attitude was contributing to the general problem. My relative satisfaction with health care that was less terrible than others’ kept me from seeing how disastrous the entire system was, and how much better it could be. Every American could and should have parental leave better than what my wife and I had. If Austria could do it, why not us? Every single citizen of Austria, regardless of status and wealth, had better choices than I did. I had been duped, like many Americans who have less-bad access to health care and public services. Everyone, my friends sensibly proposed, should have the same options, and those options should allow a family to make it through.

I enjoyed pushing a stroller around the city. I’d like to think that I would have done this anyway, but it 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.

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.

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. Politicians who summon mass death with their own actions, as Mr. Trump did, will present it as inevitable, not their fault, the work of enemies, and then apportion the dying in a way that suits them. Death, and the fear of death, become political resources. Rather than extending health care to all, a tyrant will watch people die, and try to stay in power by riding the roiling emotions of the survivors.

Journalists saved American lives in early 2020 by forcing an unwilling president to confront, if fitfully and belatedly, the reality of the coronavirus. Fatally, many Americans saw the confrontation between Mr. Trump’s witchcraft and reporters’ fact-checking as a partisan disagreement. Coronavirus seemed abstract because Americans had little or no local information about it. Since people did not know that the virus was already loose in their communities, that hospitals were already dealing with unexpected respiratory ailments, that nursing homes were already piling up bodies, the conversation in the White House seemed to be about politics rather than health, ideology rather than epidemiology.

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.

Commercial medicine means tension over bed space. When the coronavirus plague reached the United States, we did not have enough hospital beds. This might seem strange at first: aren’t epidemics regular events, and might there not be many occasions when more beds are needed than are regularly used? 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. 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.

In the hospital, sad to say, a body is a widget. Kindly assistants, competent nurses, and decent physicians try to humanize the widget, but they are constrained by a system. A body creates revenue if the body is the right kind of sick for the right length of time. Certain kinds of illnesses, especially ones treatable (or reputed to be treatable) with surgery and drugs, make money. No one has an economic incentive to keep you healthy, to get you well, or for that matter to keep you alive. 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.

hospitals as institutions have an incentive to get you out the door when the revenue stream declines, which is not the same thing as an incentive to return you to health. Insurance companies have an incentive not to pay for your tests and treatment. Every time you are seen by a doctor or a nurse, every time a test is run, the algorithms of the hospital duel with the algorithms of the insurance company to see who will make how much money. Hospitals will tend to carry out procedures that are profitable, regardless of whether they have the best personnel on hand. If, for example, your newborn has a complicated heart defect, the local children’s hospital might not direct you to the surgeon in another hospital who can best perform the demanding procedure, but will likely claim that its own surgeons are up to the task—even when this is not true. Babies then suffer and die.