April 8, 2021


THE HOSPITAL: Life, Death, and Dollars in a Small American Town By Brian Alexander 320pp. St Martin’s Press $28.99


The business of sickness is perverse. In too many instances, medical interventions are ineffective Band-Aids. Other factors, like where you stand in the social, racial and economic pecking order — and what ZIP code you were born in — determine far more about your health. As Bertolt Brecht said so well, in his “Worker’s Speech to a Doctor”:
When we’re sick, we hear
You are the one who will heal us.
When we come to you
Our rags are torn off
And you tap around our naked bodies.
As to the cause of our sickness
A glance at our rags would
tell you more. It is the same cause that wears out
Our bodies and our clothes.


In “The Hospital: Life, Death, and Dollars in a Small American Town,” Brian Alexander shares this reality from the perch of a struggling rural hospital, known to its Bryan, Ohio, community as the “Band-Aid Station.” While the nonprofit hospital fights to stay solvent and independent, each day brings new gut-wrenching stories. From the C-suite’s tension-filled strategic planning meetings to life-or-death moments at the bedside, Alexander nimbly and grippingly translates the byzantine world of American health care into a real-life narrative with people you come to care about.


Reporting over a period of two years, which only ended this past August, Alexander went into exam rooms, patients’ homes and pathology labs, and rode along with ambulance crews. He provides a deep investigative account that chronicles the staff of nurses, doctors, technicians and administrators trying to keep the patients of northwest Ohio alive.


You will root for the hospital C.E.O. who is tiptoeing around minefields, and for the immigrant doctors who are decidedly unwelcome in Trump country, even as they try their best. But the work is grueling and the lives are almost impossibly hard to save. In sensitive portrayals, Alexander shares how patients become sicker as care is delayed, costs spiral out of control and all too often patients die from preventable deaths. The entire mess is plagued by a malignancy of despair. Everybody in this story is drowning.


Just as Brecht captured in 1938, what often makes patients sick are conditions we don’t see — or choose not to see. Alexander identifies them with surgical precision, the underlying pathogens of pernicious poverty and the widening chasm of income inequality. Add in systematic racism, early childhood trauma and inequitable access to healthy food, healthy air and high-quality health care, and you have a perfect storm.


What transpires in “The Hospital” isn’t an aberration, though, and it isn’t only small-town Ohio that Alexander is telling us about. Weaving in the power- and profit-driven history of American health care, he describes how “the system had grown by accident, by ad hoc ‘solutions’ over many years, decade upon decade.” Policies with unintended consequences dating back to postwar prosperity forced employers to offer health benefit packages as a way to entice workers and avoid wage controls, eventually leading to our tragically bad employer-based model of health care.


When the Reagan era brought a decline in union strength and workers’ rights, and greater economic inequality, things started falling apart. “Fewer people were able to stand on the shoulders of their parents to make the all-American climb,” Alexander tells us. And the system began its slide to perversity.


“The modern American version of capitalism encouraged — even demanded — that employers extract the value from their employees while returning scraps to them and their communities.” As the decades passed, employers offered less robust health care coverage. For most, it became a sort of game: how to whittle down the care being offered and make everything indecipherable so nobody would notice how little coverage there really was. Smaller local hospitals and individual practitioners joined chains to survive. Health care stopped being about those moments of healing that occur between a doctor and a patient. Far removed from the bedside, it became about big money run by monopolies and corporations.


Public health systems were eroding during the same time, he writes, “from inattention and financial starvation in the same way other public goods like bridges, water systems and education eroded, and so the health of Americans eroded, too.” Alexander’s book places a stethoscope on America — and the diagnosis is bleak. It wasn’t an epidemic of viruses, but an epidemic of greed, that corroded the social contract and public health. Our country’s promise has evolved from “an ongoing project to improve democratic society and live humanistic ideals to being a framework for fostering corporate profit.” We don’t need more biopsies or autopsies, or drugs that cost more than a mortgage. It is unchecked capitalism that is making us sick.


Alexander’s reporting takes us into the pandemic, our system’s biggest moment of reckoning, and suggests it could offer an unexpected opportunity. After half a million deaths, Covid has exposed two false narratives: individual behavior as the sole cause of poor health, and universal care as an “evil of socialized medicine.” Things don’t have to be this way; we can do more than hand out Band-Aids. If health care is a public good, then public institutions should replace the for-profit models and profit-motivated private systems, and it should finally be a universal right, untethered to employment.


By the end of “The Hospital,” you’ll be making signs to carry at the next Medicare for All march. With the stories of these characters — from patients and doctors to the C.E.O. — etched in your heart, Alexander will make you see that a healthier America will only be realized when we begin to look beyond the patients in front of us and prescribe solutions that lift people out of poverty, eliminate inequities and respect the dignity of all.


Brian Alexander’s book sometimes reads like post-apocalyptic science fiction. He pushes us to ask, How can citizens of the richest nation in history allow loved ones to die because we can’t afford lifesaving medication, like insulin, while C.E.O.’s of for-profit hospitals earn millions per year?



Mona Hanna-Attisha (@MonaHannaA) is a pediatrician and professor at Michigan State University College of Human Medicine in Flint. She is director of the Pediatric Public Health Initiative and author of “What the Eyes Don’t See: A Story of Crisis, Resistance, and Hope in an American City.”


This review first appeared in the New York Times