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"The Hospital: Life, Death, and Dollars in a Small American Town”| Reviewed by Bill Schwab

Updated: Oct 21, 2021

Journalist and master storyteller, Brian Alexander delivers an astute, gut-punching study of the U.S. health care establishment. He does so by focusing on one small, independent hospital in Bryan, Ohio, the Community Hospital and Wellness Center, locally known as “The Band-Aid Station.” Bryan is a rural city 50 miles west of Toledo; population 8500.

Alexander draws on more than two years of research and observation of CHWC. He describes and reflects on the effect of major administrative decisions, witnesses emergency room crises, views exam rooms, visits patients’ homes and observes pathology labs. He rides along with ambulance crews and judiciously analyzes the hospital’s history and current key documents. He concludes that Bryan “wasn't much different from any other places...[it] was a microcosm of American sickness.”

His study is presented mostly chronologically: “Autumn, 2018,” “Winter/ Spring, 2018- 2019,” and “Winter/ Spring/ Summer, 2019- 2020.” The chronology is occasionally interrupted by extended discussions of critical boardroom issues, emotional stories of disadvantaged and uninsured patients, and thoughtful consideration of more expansive issues such as the tensions between those who favor universal healthcare and those who oppose it.

Hospital CEO Phil Ennen is central to the whole story. Ennen “believed he could juke and jive his way through American healthcare to keep CHWC as it was-- and even grow it.” But he found it to be a challenge to keep CHWC solvent without lowering the level of care. His inability to handle this problem creates infighting among board members and controversy in the community.

Interwoven in the account are critiques of the devolving state of health insurance, the competition for business with mega-hospital corporations, price-fixing by pharmaceutical companies, and the correlation of socio-economic class and wellness. In one of his most excoriating observations, Alexander notes that the U. S. has “changed from being an ongoing project to improve democratic society and live humanistic ideals to being a framework for fostering corporate profit.”

The journalist’s tangents provide some of the most thought-provoking elements of the book. For example, he discloses the negative effect anti-immigration policies have had on attracting foreign doctors to small hospitals. Rural independent hospitals rely on foreign doctors for staff since they are more willing to work in more isolated locations than native-born physicians.

And in another agonizing side story, he details the economic difficulties of 39-year-old diabetic Keith Swihart who undergoes “two amputations, three eye surgeries and one colonoscopy,” as an example of the excessive hardship placed on a family because the U.S. does not provide universal healthcare. By focusing on an independent, small rural hospital, Alexander shrewdly demonstrates how healthcare systems impact the lives of individuals and communities.

In the Epilogue, Alexander’s research uncovers why the state of hospitals led to the crisis in addressing the COVID-19 pandemic. The pandemic “stripped away the fiction” that healthcare in the U.S. had not before now reached a crisis point. Many hospitals were put in a fragile position by COVID-19 because they were already running lean to keep costs down. He argues hospitals have lost their mission. Rather than ask “How can we provide quality health care to the public?” hospital systems ask, “How do we get a return on investment?”

“The Hospital” makes a deep dive into the world of the American medical industry. The book validates the jarring statistics signaling that Americans are dying sooner and living in poor health. Public health systems are eroding “from inattention and financial starvation in the same way other public goods like bridges, water systems and education eroded” he maintains.

The author holds that no plan will solve America's health crisis until the underlying causes making America sick are addressed. With surgical precision, he identifies those basic causes: insidious poverty, the widening chasm of income inequality, systemic racism, the frequent presence of early childhood trauma, and inequitable access to healthy food, healthy air, and high-quality health care. Alexander argues that we do not need more biopsies or autopsies, or drugs that cost more than a mortgage: Rather, he says, it is unchecked capitalism that is making us sick.

About the Author: Brian Alexander is a contributing writer to “The Atlantic.” He has spoken in Washington to members of the Senate and House of Representatives. Alexander is the author of “Glass House” which examines what happens to a community when a major industry leaves. He is a winner of the Ohioana Book Award.

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