The People's Hospital: Hope and Peril in American Medicine
by Ricardo Nuila
Scribner 2023

Healthcare costs in the United States are approaching 20% of GDP, a figure significantly greater than that of any other developed nation. Their growth has been expanding at percentages exceeding rates of inflation, frequently double these rates. Life expectancy in the US is falling, and US healthcare consumers vis a vis their counterparts elsewhere are spending more and getting less. Yet, in a July 20, 2023 JAMA Health Forum article, Larry Levitt, noted that “this may be the first presidential election since 2008 when health reform…[is] not front and center.” This is a shocking state of affairs, particularly as corporate entities continue to transfer more healthcare responsibilities to their employees, and numbers of uninsured Americans increase. Fortunately, in the midst of this, an emotionally stimulating book by physician Ricardo Nuila, The People’s Hospital: Hope and Peril In American Medicine, offers insight into the US healthcare situation and provides some thoughts (and hope) as to what might be done.

Nuila, an associate professor of medicine at Baylor College of Medicine, is a doctor and teacher of internal medicine at Ben Taub Hospital, a public healthcare facility located in Houston, Texas. His role in writing The People’s Hospital is largely that of a storyteller. The stories he tells relate mostly to the medical experiences of five of his Ben Taub patients, all of whom are uninsured: Roxana, Stephen, Ebonie, Christian, Geronimo, and Aqueria. He melds his stories with a variety of personal perspectives: that of a son, reflecting on the career of his doctor father; that of an international volunteer, recalling his experiences in Brazil, India, Kenya, El Salvador, and especially Haiti; that of a husband, remembering the baby-delivery process of his wife, and the problems encountered therein; and, that of a grandson, thinking back to the emotions and frustration he dealt with in trying to manage the end-of-life experiences of his grandmother (Abuelita). Something else Nuila does is to compare/contrast Ben Taub’s situation with that of its predecessor, Jefferson Davis Hospital, relying on a portrayal depicted in the book, The Hospital, by the late Dutch author Jan de Hartog to do so.

Dr. Nuila makes it clear that he believes that the current US health system, one he terms Medicine Inc., is broken. Among the major problems requiring change are the fee-for-service basis of American healthcare, an approach that incentivizes over-application of medical services; a reliance on health markets, when such markets do not really exist (due to informational asymmetries; monopoly-like service structures; and, minimal service choices, among other reasons); and a system that rewards treatment of sickness over maintenance of health. Something odd about Nuila’s depictions, however, is why more isn’t being done to engender change? This Nuila attributes to a mindset associated with “disaster syndrome,” which exists “when normal reactions to protest or outrage in the face of intolerable conditions are absent and the overriding reaction is not to correct those conditions but to accept them as permanent and to circumvent them.” Nuila concludes that doctors in the US now experience extremely high levels of disaster syndrome, and, as a result, they “don’t like practicing the American style of medicine anymore.” This is frightening.

A notable aspect of The People’s Hospital, apart from Nuila’s captivating and oftentimes heart-wrenching stories of his five+ patients, is that the book includes many suggestions as to how the US healthcare system might be improved. Some of these are explicit, and others implicit. Together, however, they provide enhanced understanding for how to positively reform US healthcare. Ben Taub serves as the basis for this, a place “where science and people and costs all overlap.”

More than anything, Nuila asserts that doctors should be given a better opportunity to connect with and serve their patients, with incentives in place motivating them to keep their patients healthy. This might seem obvious, but under the current system it is mostly not true. Instead, doctors are encouraged to scientifically evaluate their patients, minimizing doctor-patient rapport, with extant incentives emphasizing sickness over health. In terms of costs, within hospitals, there should be less focus on aesthetics (e.g., pianists and waterfalls in hospital lobbies), privacy (i.e., allow for semi-private rooms and open wards), and certainty (the rise from 99% to 100% is extremely costly), and more on coordination of care and on the consideration of appropriate health care strategies, particularly in end-of-life scenarios. Nuila also contends that the emphasis on profit in healthcare is inappropriate to how a healthcare system should be defined. Change is needed.

The People’s Hospital is highly recommended. The book makes evident that US healthcare is veering towards crisis, and that if left unchecked, implosion will occur. As Americans, we deserve better, and Nuila’s work provides insights as to how positive change might occur.

Mark Jacobs is a former business school professor with an interest in the intersection of society and business, Mark lives in North Carolina.