Abstract
The Hospital, Brian Alexander’s account of health care in Bryan, Ohio, is an emotionally and politically astute study. Alexander draws on more than two years of journalistic research, including extensive interviews, observation, analysis of documents, and investigations into the history of health care provision in the United States since the 1800s. Alexander notes that Bryan “wasn’t much different from many other places . . . [i]t was a microcosm of America’s sickness” (p. 248). Using Bryan as a microcosm, Alexander adeptly demonstrates how systems of health care impact the lives of individuals. The Hospital indicates an interplay of structure and agency by drawing connections between the struggles of Bryan residents and societal inequalities and profit imperatives.
The text is broadly chronological, with three parts that cover “Autumn, 2018,” “Winter/Spring, 2018–2019,” and “Winter/Spring/Summer, 2019–2020.” However, the narrative surrounding the hospital itself is broken up by descriptions of the history of Bryan and of health care in America, by descriptions of neighboring hospitals, and by evocative detailing of the lives of hospital patients and employees. For example, the prologue introduces the reader to Phil Ennen, CEO of the hospital in 2018, to doctors, and to patients. Then the first chapter is more expansive. It details attempts to establish a hospital in Bryan, and the tensions in America between efforts to universalize and equalize health care and opposing efforts against any “socialization” of health. Initially, these shifts between the immediacy of concerns of Bryan residents and the broader picture of health care feel disorienting, but it is a skillful way of demonstrating that failings in health care systems have real effects. Alexander follows patients through their care as they suffer heart attacks, cancer, bereavements, amputations, all while navigating overwhelmingly convoluted health insurance systems and living on a financial knife edge. These emotive depictions of individuals’ lives are perhaps the greatest achievement of the text. By taking this granular view, Alexander is able to demonstrate that the health of individuals in Bryan is inextricably connected to their employment, their accommodation, and their access to transport and to fresh food. Employment is significant here, particularly given that employers frequently have (often inadequate or inaccessible) health insurance systems. Beyond individual employment though, Alexander relates the “sickness” of inequality and failing health care to America’s capitalist economy. He writes: “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” (p. 247). The health industry is like any other industry under this capitalist system: focused on its bottom line.
The Hospital describes these pervasive issues within health care without applying any explicit theoretical lens. For example, Alexander uses distinctly Marxist terminology when describing employment as an extraction of value, but Marx himself does not get a citation. Alexander is primarily conveying stories and situating those stories rather than entering into academic debate (although the acknowledgments note a number of academic texts that provided background to the research), and the breadth of the analysis, covering contemporary institutions and historical shifts in attitudes, leaves little room for theory. Alexander’s descriptions of institutions, of “the jumble of ill-fitting building blocks” (p. 252) of doctors, hospitals, insurance, providers of drugs and of medical devices, can be confusing for a reader (like myself) who is unfamiliar with health care in America. Yet, he successfully grounds the interactions between institutions using the experiences of Bryan residents, emphasizing that areas such as financing and lobbying in the health sector might seem disparate to “immediate and pedestrian” concerns but, in fact, “mattered a lot” (p. 173).
The methods used by Alexander to research and report upon the lives of people in Bryan are not a focus of the text, distancing Alexander’s approach from texts concerned with academic rigor. The acknowledgments at the end of the book provide some insight into his access to the hospital but Alexander does not discuss decisions made throughout the ethnographic research process (such as why Bryan was selected, why interviewees were selected, and what the interviews or observations consisted of) or discuss his own position as a journalist at the hospital. Brief comments hint at difficulties in the research process when the leadership at the hospital began to crumble: His presence at this time caused concern for lawyers, and somebody involved in the ensuing power struggle declined to be interviewed on particular topics. There are also some poignant insights into the close relationships that Alexander develops with patients at the hospital. In particular, he appears close to Keith, a recently widowed Bryan resident whose health concerns—and financial difficulties—seem to grow exponentially. Alexander and Keith sit together at the grave of Keith’s wife; Alexander drives Keith to appointments. Their close relationship is apparent when, in an effort to reassure Alexander that he is not suicidal, Keith says, “I know you’re worried about me” (p. 257). This worry would be understandable, as suicide and reactive or situational depression are ever-present throughout the text as a markedly common but often undiagnosed symptom of health and economic inequalities.
As The Hospital progresses, Bryan hospital seems to be hurtling toward a cliff edge, with CEO Ennen besieged by funding obstacles and, on occasion, his own questionable decision making. But another cliff edge appears—COVID-19. As a reader, the knowledge that the hospital and the Bryan residents will soon face cataclysmic challenges creates a feeling of dull inevitability. The epilogue discusses the effects of COVID-19 on the community of Bryan, and Alexander stresses that the pandemic “stripped away the fiction” (p. 270) that health care in America had not already reached crisis point. Similarly despondent texts might end on a note of hope; Alexander does not take this approach. To do so would, I think, have been disingenuous. If Joe Biden had been elected president before completion of The Hospital, there might have been some room for a hopeful finishing flourish, but perhaps the problems detailed by Alexander are too endemic for one election to shift. Alexander demonstrates that a failure of personal responsibility, blaming noncompliant patients and indolent workers, acts as a more convenient—but ultimately misleading—narrative than the reality of systemic economic inequalities under America’s capitalism. His argument is journalistic rather than self-consciously academic, but The Hospital will be a compelling read for academics (or students) interested in the impact of capitalist work systems on health. Alexander’s analysis is insightful and compelling; above all, it is empathetic.