Book review of Our Malady: Lessons in Liberty from a Hospital Diary by Timothy Snyder

His condition worsened, and on Dec. 29, back home in New Haven, where he teaches history at Yale University, he spent 17 hours in the emergency room before a diagnosis was finally made. He now had a baseball-size abscess in his liver, accompanied by bacteria in his bloodstream. He was on the verge of death from overwhelming sepsis. It was probably a complication of a burst appendix.

After emergency surgery, instead of gratitude that he was alive, Snyder felt rage. In fact, rage is the leitmotif of his slender new book, “Our Malady: Lessons in Liberty From a Hospital Diary,” with more than 30 occurrences of the word, averaging roughly one “rage” every five pages.

His central argument is this: America is supposed to be about freedom, but if our health-care system makes us unhealthy, it is making us unfree. Health care, Snyder writes, is a fundamental human right, as laid out in the Constitution. “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,” Snyder writes. “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. . . . The right to liberty implies a right to health care. We are not free when we are sick.”

Synder’s point about our right to health care — and the flaws of America’s health-care system — is not a new one. There are hundreds, perhaps thousands of books, articles, studies, blogs and podcasts on the inefficiency and inequity of the U.S. health-care system. Buttressed by data showing equal or better outcomes at far lower costs in countries ranging from New Zealand to Norway, this mountain of literature accuses the American system of suffering from its own set of diseases, whose causes are variously attributed to profit maximization by a variety of villains — hospitals, pharmaceutical companies, insurance companies, etc. — and general insensitivity to the needs of patients. Sometimes physicians are put in the villain category; in other cases, they are let off the hook as well-meaning but ineffective cogs in a corporate system in which they have lost all control.

Snyder’s Thomas Jefferson-invoking tenet is a gussied-up version of these arguments. Other problems he points to as subsets of the larger one have also been examined and discussed at length. So the reader is given cause to ask: What’s new here?

There’s an initial thrill when reading Snyder’s take on American health care. He’s a brilliant historian whose deep understanding of the origins of fascism and the lessons of the Holocaust made his best-selling book, “On Tyranny,” published on the heels of the 2016 presidential election, all the more credible. And his critique that the health-care system is organized in a way that maximizes profits for a few, wastes a lot of money and too often leaves patients confused, lacking access and feeling uncared for is correct.

Yet the unimpeachable authority that made statements in “On Tyranny” such as “post-truth is pre-fascism” feel chillingly real is missing in “Our Malady.” Snyder is clearly an authority in his discipline but not one on health care.

His chapter on doctors is a case in point. Here, the author puts his money squarely on the doctors-as-powerless-pawns theory, as opposed to the doctors-as-greedy-and-unfeeling-oafs one. Physicians, he writes, have shifted from being like the all-knowing and ever-caring 1970s TV creation, Dr. Marcus Welby, to being an “enserfed” medical workforce. They are mere “props in advertisements.” The health-care providers who spent only a few minutes with Snyder, or sometimes barely seconds, did so not because they are bad or uncaring doctors, but because they are squeezed by both the huge medical conglomerates for which they work and the insurance companies that call so many of the shots.

The consequences of commercial medicine are most evident in hospitals, Snyder writes, where the human body is a widget. Those charged with taking care of the widget try to humanize it, but the system constrains them. “No one has an economic incentive to keep you healthy, to get you well, or for that matter to keep you alive,” he writes. The first two assertions might be true. The indictment that the U.S. health-care system overemphasizes sick care over primary care and wellness has been made often, and is largely correct. But is he saying that the systems in which he received care failed him because they lacked a financial incentive to keep him alive? One would want strong support for such a statement.

Snyder favors big political points: notions of liberty and freedom and how they connect to the imperative to create a health-care system that is equitable and just. However, in doing so, he mentions only in passing one of the main causes of physician burnout and distraction. Doctors spend half their time on a keyboard, slaves to the electronic health record. As a result of this — and the accompanying pressures to document extensively for purposes of billing, quality measurement and lawsuit prevention — physicians aren’t as much stripped of their ability to care for patients as just plain worn down. In other words, while Snyder’s diagnosis of an overworked and frayed physician workforce may be accurate, its underlying causes are more subtle and more numerous than he might have us think.

He is right in asserting that the outcomes of patients in many other countries are as good as or better than those in the United States — all at lower costs. Yet it was in Germany, a country he goes out of his way to praise, that his abdominal pain was first misdiagnosed.

Still, there’s always a place for a good rant, and the American health-care system is perfectly rant-worthy, as it edges closer to extracting 20 percent of the nation’s gross domestic product, with mediocre outcomes to show for it. As rants from patients done wrong go, Snyder’s is loud and lucid. His litany of the many ways the United States bungled the coronavirus response is eloquent and pointed. And just in case you haven’t heard these things before, his cry of rage is certain to get your attention. After all, it’s hard to refute a claim that Americans deserve a medical system that works. “Does that sound like a dream?” Snyder asks at the end of “Our Malady.” “Let it be the American one.”

Our Malady

Lessons in Liberty From a Hospital Diary

179 pp. $12 paperback

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