After he finished medical school, my father left India, moved to the United Kingdom, and became a surgeon in the National Health Service. He specialized in orthopedics, which made Christmas a busy time for him. Icy sidewalks and boozy seasonal parties meant a steady stream of broken hips and car accidents. On Christmas morning, he would take the family on a round of the London hospitals where he worked to visit the patients stuck there for the holidays. It was a tradition, a mark of goodwill—most of the doctors we knew did the same thing—but also a recognition that medical care involved more than just the provision of treatment. Many of the patients, particularly the very old ones, had no other visitors. We substituted for the family they didn’t seem to have.
These visits were intense experiences for a small child. I remember the smell of Seventies English institutional food and the cheerful women serving it, their uniforms spruced up with tinsel and sometimes a cheeky sprig of mistletoe. I remember toothless old fellows in striped pajamas, paper hats askew. Often my father would be asked to examine someone, or confer on a set of test results, and I would be left to gorge myself on snacks in staff rooms where bottles of alcohol were lined up, ready for end-of-shift parties. There I would be plied with fizzy drinks and fussed over by nurses who had already been into the sherry.
I submitted to the touches of bedridden strangers, my wrist gripped and my cheek pinched by people who would tell me my father was a wonderful man. He was good with patients, particularly the old ones, raising his voice slightly and twinkling his eyes. He knew that they were often scared, and that they were looking to him for optimism and reassurance. I saw people who were in pain, agitated, or confused. I saw how one patient could be alone and in distress, while around their neighbor’s bed a family would be gathered, happily excavating a tin of assorted chocolates.
One year in the intensive care unit, I looked through a glass partition into a room where a young man lay hooked up to monitors, his head heavily bandaged and his legs attached to a complicated traction system of weights and pulleys. My father itemized his terrible injuries and made me promise never to ride a motorbike, a promise I solemnly made. Sometimes we visited his colleagues in the emergency room, and there I caught glimpses of people in crisis. I saw police dealing with drunks. I saw a very old woman, her skin a terrible shade of yellow, taking what appeared to be her last breath, a horrible rattling sound. I saw medical staff, particularly junior doctors, who were visibly exhausted as they came to the end of brutally long shifts. Then I went home and opened my presents.
I grew up in this world, in a house littered with boxes of patient notes and teetering piles of medical journals in which the unwary browser would be confronted by every kind of bodily unpleasantness, from genital warts to maxillofacial surgery. I wrote my homework with drug company ballpoints and at least once went to school with a jar containing some kind of diseased bone sample, swimming in murky formaldehyde.
My father split his time between NHS work and private practice. As I got older, his practice grew, and we moved into a bigger house, which duly filled up with the detritus of his professional life. My mother booked his appointments and grumbled about the “pushy” private patients who felt entitled to his time, day or night. I never thought to question the foundational premise of this way of doing medicine. Health was a basic right, not something to be purchased on the open market. Private care allowed for single rooms and shorter waiting lists, a doctor who would take your call on a Sunday afternoon, that was all; it was a supplement to the service we all paid for with our taxes.
When I moved to New York, many things seemed strange. Among them were the crutches I saw discarded on the street, leaning against the hunter-green fences of construction sites or on the steps of the public library where I had an office. It felt like finding evidence of miracles: the lame had risen up and walked. Later I learned that people were often expected to buy such items, rather than being given or lent them by a health provider. Once finished with them, they naturally enough threw them out. I connected this in my mind to the chronically ill people I saw living on the street, many with mobility issues—people who seemed to need care and weren’t getting it, like the woman nodding out on the corner in a wheelchair, or the man wearing nothing but a hospital gown, looking as if he’d been discharged from a psych ward straight into Tompkins Square Park.
As a freelancer, I bought my own insurance—my second-largest expense after rent. Despite spending hundreds of dollars a month, I still had to hand over something called a copay to be seen by a doctor. When I expressed shock at this fact, my American friends laughed bitterly. Step by step, I was initiated into this strange new health culture, so different from the one I was used to. Why did I need permission from the insurance company if my doctor thought a treatment was necessary? This was a medical decision, wasn’t it? In that first year, I went to see a physiotherapist and realized that he was shamelessly upselling me, trying to persuade me to embark on a complicated and expensive course of treatment that I didn’t need. Oddly, this disturbed me most of all. I was used to a system where there was no incentive to do such a thing, and it felt like a breach of trust. Deep inside, I was still the doctor’s kid, conditioned to see medical professionals as benevolent authorities.
I began to hear horror stories: the uninsured woman who slipped in a gym changing room, knocking herself unconscious, then woke up and tried her best to stop the ambulance from coming, as she couldn’t afford the cost; the young musician who’d tried to set his own broken arm using instructions from the internet. Everything seemed absurdly marked up ($1,830 for a pair of orthotic insoles?), and hovering over us all was the threat of medical bankruptcy. It was mind-bending to think that I was one serious illness away from losing my life savings. I contributed to GoFundMe campaigns and began to experience something new, a low-level background anxiety.
The U.S. health care sector is massive. In 2020, it amounted to 19.7 percent of GDP. In the previous (pre-pandemic) year, that number was 17.6 percent. The United States spends more on health care than any other developed country, and not by a small amount: $12,318 per capita in 2021. In the rest of the developed world the average is under $6,000. What do we get for all this money? Lower life expectancy and higher infant mortality than almost all other developed nations. Despite the huge deployment of resources, the system is, by almost every metric, a dismal failure.
How this state of affairs came about is a complex and unedifying story. In The Next Shift, his account of Pittsburgh’s transformation from a steel town to a health care hub, the historian Gabriel Winant describes the system that arose in the middle of the last century, after the Truman Administration’s attempt to pass universal health care did not even make it to a vote. Tax breaks created enormous incentives for both workers and employers to make health insurance a large part of compensation. Powerful unions negotiated comprehensive coverage for their members, while the establishment of Medicare and Medicaid covered the poor and the elderly. For those within the system, it worked well, but many were left out, and the economics of health care would now be driven by an inflationary cycle, as providers and insurers effectively colluded to bill and recoup more.
Winant also recounts how deindustrialization destroyed the union jobs that came with good health insurance. As the last cohort of well-insured steel workers moved into retirement, their extensive health needs were serviced by a growing army of hospital workers who were themselves not allowed to unionize. Their precarity represented the future of the working class—a low-paid workforce with few rights or protections, performing service labor for the fraction of the population able to afford it. As of 2021, 12 percent of all jobs in the United States are in health care and social assistance. That’s more than manufacturing, more than retail. The fastest growing occupation? Nurse practitioner, just ahead of wind turbine service technician.
And so we reach the present state of dysfunction, where drug companies can charge $100 a vial for insulin ($8 a vial in the United Kingdom, but free for consumers) and insurance companies own hospitals and medical practices, effectively buying services from themselves at prices that allow them to extract huge profits. The problem is not just the inflated costs, but the artificial restructuring of medicine as a series of billable encounters, a model that is convenient for taking payment, but that degrades all other forms of non-acute care.
There is a fantasy of health as an individual property, a condition toward which we should each strive, alone in the gym. The tech founder Bryan Johnson circulates pictures of himself wearing some kind of matte black headset and kneeling in an empty, glass-walled room. He claims to have “reduced [his] epigenetic age by 5.1 yrs in 7 months” through a strict program that incorporates exercise, diet, and the ingestion of improbable quantities of supplements. Johnson’s quest to buy himself additional years of life exemplifies the ideology of health as a kind of self-optimization, a triumph of individual will.
Against this picture, we have images of the pandemic: wards packed with patients on ventilators, people standing in line to get vaccines, groups performing various communal activities while masked and socially distant. Fights about lockdowns aside, the pandemic demonstrated all the ways that we are interdependent, our health tangled up with that of our neighbors. And quite apart from the risks of infectious disease, health has social as well as biological determinants. The environment we live in, poverty, access to education, even the quality of our relationships—all have proven effects.
If one man can be said to have been the architect of the British National Health Service, it was Aneurin “Nye” Bevan, a coal miner from South Wales who had watched his father die of black lung. Bevan became a union activist and then a Labour Party politician, serving through the Depression years. He was the health minister in the Clement Attlee government of 1945, which was swept into power on the promise of a welfare state that would look after its war-weary citizens “from cradle to grave.” I have a copy of a book Bevan wrote—part manifesto, part autobiography—called In Place of Fear. The title strikes me very forcefully these days.
The American health system, as it currently exists, functions as a form of social control, an engine of unfreedom. The disastrous linkage of coverage to employment reduces individuals’ ability to move, to make choices, and to take risks. It makes them beholden to their bosses. Medical debt stunts lives and blights futures. For generations, Americans have been conditioned to fear the threat of “socialized medicine.” It’s a fear that has its basis in the cultural memory of the carceral system of asylums and public hospitals that were once sites of neglect and cruelty. It has also been carefully promoted by those who have a vested interest in the maintenance of the status quo. The truth is that Americans would be a great deal more free if they were liberated from the predations of a medical system that has become a parasite on the social body, extracting wealth and energy that could otherwise be directed toward human flourishing. It is time to tear it down and build something new in place of fear.
