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                                                                                                                                 a small facility like CHWC.                             “Over years — over two generations — they’d become part of a cul-
        The Health Care                                                                                                          one day heaved and strained too far, blowing two discs in her lower   ture of defeat, what doctors liked to call noncompliant … but noncom-
                                                                                                                                   In Valerie*, we have an incredibly hard worker – three jobs! — who
                                                                                                                                                                                       pliant in a bigger sense. They no longer complied with society’s
        House of Cards                                                                                                           back. “Workers’ compensation covered her vertebrae-fusion surgery   prescriptions. They were either unable or unwilling to obey. Maybe
                                                                                                                                 and physical therapy afterward. But then the recession hit.” Her job
                                                                                                                                                                                       some of them had tried to obey, once, but obeying didn’t lead anywhere
                                                                                                                                 disappeared.                                          better, or obeying was just too difficult because everything cost so
        By David Alex Schulz, CHP                                                                                                  In the book, we see obesity, over-work, hypertension and cardiac is-  much, or was so hard to achieve, and so they said to hell with it.”
                                                                                                                                 sues as plaguing suburbs and cities alike. Alexander then discusses ad-  Such attitudes, whipsawing people with contradictory messages and
                                                                                                                                 diction as a public health issue. As Alexander points out, “Sociologists   magnified by a media alarming the public, leads to a suspicious, dog-
          If American health care were its own patient, "code blue" might be a                                                   had tried for years to tell politicians that drug abuse was a symptom,   matic polarization that COVID-19 lay bare. “The Hospital,” while ini-
        generous call. It has never been closer to flatlining, according to Brian                                                not a cause. The kind of drug was irrelevant … alcohol might be more   tiated years before the current crisis, deals with the pandemic as its
        Alexander’s “The Hospital: Life, Death, and Dollars in a Small Amer-                                                     immediately dangerous than obesity, lousy dental care, poverty and low   fitting epilogue, a capstone that provides fitting validation for Alexan-
        ican Town.” His exam of natural and artificial forces acting on a typical                                                wages, crummy housing, depression, trauma and anxiety. They were all   der’s insights.
        health care facility leaves the reader shaken and disturbed – particularly                                               part of the same pathology, though, and arguing about which was
        as the content largely precedes COVID-19.                                                                                worse obscured the underlying causes of the abuse.”     All quotes from “The Hospital: Life, Death, and Dollars in a Small
          Alexander’s analysis of a system gone awry focuses on the Community                                                      Herein we find Alexander’s primary thesis: the isolating of health care   American Town” by Brian Alexander, St. Martin's Publishing Group
        Hospitals and Wellness Centers (CHWC) of Bryan, Ohio: a microcosm                                                        as a separate, biologic-only function fouls our approach from the begin-  March 2021, Kindle Edition.
        through which to see the whole. The author is a storyteller. “The Hospi-                                                 ning. To distinguish addiction, depression, or suicidal tendencies as sep-
        tal” is a narrative history, not a chronologic recounting. Through the eyes                                              arate from obesity, coronary-disease or cancer is to look only at the    David Alex Schulz, CHP is a community member of the
        of patients, physicians, staff and governance, we see generosity, greed and                                              manifestations of a deeper, underlying and more widespread epidemic.     BCMS Publications Committee.
        the effects of happenstance and planned malfeasance.
          In Bryan as elsewhere, public service health care only gained mo-
        mentum after the Spanish Flu, but relations between private and public
        medicine, both competitive and cooperative, created an immediate,
        persistent tension. Alexander says that as early as 1929, “The AMA
        and local medical societies acted like cartels to block experiments in
        medical payment that sought to make care affordable.” When Los An-
        geles doctors formed the country’s first group care plan, the Ross-Loos
        Medical Group, the Los Angeles Medical Association expelled them.   the other,” reflects Ennen.
          Such tension left physicians uncertain and patients confused. Spot-  Detailing patients’ struggles displays that the forces acting on Amer-
        lighting the decade between the Great Recession and Pandemic allows   ican health could correlate closely with social and economic disparities.
        Alexander to contrast access to insurance with the availability of serv-  Although the 36,000 county clients of CHWC were “preternaturally
        ices. Many small-town hospitals “went bankrupt, or were absorbed   homogenous, there could be as much as eight year’s difference in life
        (and sometimes gutted) by bigger regional health systems, or the towns   expectancy from one part of the county to the next, and even from one
        themselves had slowly become more memory than living reality until   part of tiny Bryan to the next.”
        there was no point in having a hospital there at all.”   In Keith* (surnames redacted), we see the relationship between mar-
          CHWC was falling prey to the same travails: “CHWC lost money   ginal income and mordant diabetes. Keith discovers his blood sugar
        every month of 2018 … dogged by big hospital chains in Toledo and   level was more than twice the 400 mg/dL at which his reader topped.
        Fort Wayne … Both had been gobbling up small independents like   The Medicaid expansion Ohio’s governor accepted provided insulin
        CHWC for over a decade in a crazed rush to consolidate before they   support. However, when amputation made mobility an issue and only
        could be targeted themselves by even bigger predators.”   a Dollar Store (accepting SNAP) is reachable, a healthful diet is harder
          Phil Ennen, our protagonist and hospital CEO, faces these trials as   to access.
        a Bryan native and community leader. The author reminds us the title   In Marc*, we see a good-hearted person (kidney donor, community
        is from business, whereas hospitals once had ‘administrators.’ “Perform-  volunteer, model family) suffer a cardiac arrest. Hypertension, arrhyth-
        ing like a business while simultaneously taking on a mission nobody   mia, arterial blockage; America was a heartsick nation at this time, and
        fully understood meant that one goal would always be in tension with   performing cardiac catheterizations were a necessary attribute of even



         36     SAN ANTONIO MEDICINE  • August 2021                                                                                                                                                                  Visit us at www.bcms.org     37
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