Summary:

The title of this book, “An American Sickness,” refers to the author’s view that the costs people who require health care must bear in the U.S. causes its own sickness. The author, Elisabeth Rosenthal, is a physician-turned-journalist so her use of a medical metaphor to explain the harms health care costs are causing people comes naturally to her. The sickness metaphor forms the structure for the entire book, and in particular the way a physician approaches a patient with a health problem to diagnose and treat. Thus, the introduction to the book is the “chief complaint,” Part I is the “history of present illness and review of systems,” and Part II is “diagnosis and treatment.”  

The chief complaint is: “hugely expensive medical care that doesn’t reliably deliver quality results.” (p. 4) This complaint is also relatively acute given that the financial toxicity health care causes has become so extreme over just the 25-year period starting in the early 1990s. This was the time it took in Rosenthal’s view for American medicine to transform from a “caring endeavor to the most profitable industry in the United States.” (p. 4)  

The source of this complaint cannot be located in one segment of society or in one part of health care in the U.S. It’s diffuse. Therefore, Rosenthal exams several components of American health care to isolate specific causes for the financial toxicity people are experiencing—her review of systems. She exams 11 particular components, with each one comprising a separate chapter as follows: insurance; hospitals; physicians; pharmaceuticals; medical devices; testing and ancillary services; contractors; research; conglomerates; health care as businesses; and the Affordable Care Act.  

Part II on diagnosis and treatment takes the form of a how-to book, as the book’s subtitle announces. Rosenthal is speaking to health care consumers—i.e., all of us—and commanding our attention: “The American healthcare system is rigged against you. It’s a crapshoot and from day to day, no one knows if it will work well to address a particular ailment.” (p. 241) After a chapter on the consequences of being complacent with our personal health care utilization and costs, Rosenthal provides advice in subsequent chapters on these topics: doctor’s bills; hospital bills; insurance costs; drug and medical device costs; bills for tests and ancillary services; and managing all this in a digital age.  

The book is replete with case studies. The writing is geared toward health care consumers who have no expertise in any aspect of health care—it is Rosenthal the health care journalist writing, not Rosenthal the physician and health policy expert. 

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Emergency Doctor is a riveting, informative account of the workings of the Emergency Department at Bellevue Hospital in New York City, the oldest public hospital in the country.  On any given day, tourists, residents, the wealthy and those who live in shelters come to the Emergency Department, some with life threatening injuries and others who need little more than a hot meal and a shower.  No one is turned away.  

Published in 1987, the book was written by a former editor at Reader’s Digest in cooperation with Dr. Lewis Goldfrank, the former Director of Emergency Services and a leading toxicologist.  Goldfrank’s personal story of his path to emergency medicine and his experience in creating the Emergency Department out of what was once known as the Emergency Room frame the narrative, but the main focus is on the day to day activities of the patients and staff in the Emergency Department.  Because Bellevue is NYC’s main trauma center, the book is rich with stories of trauma including construction accidents, cardiac arrests, fires and suicide attempts among others.  Even the title chapters-- "A Question of Poison," "An Alkaloid Plague," "The Case of the Crazed Executives," for example—convey the urgency and medical detective work needed for each person who comes through the triage area. 
“We don’t know if a patient is alive or dead when we first see him,” Dr. Goldfrank says.  “And we’re never sure what we’re going to find, or what kind of emergency medicine we may be called upon to practice—surgery, neurology, pediatrics, psychiatry, cardiology, obstetrics. (p118)   Accident victims are stabilized in the trauma area and rushed to the operating room. People with cancer, or TB, children who have been abused, broken bones, suicide attempts, accidental or intentional poisoning and overdoses—all must be evaluated and decisions made whether they should be admitted to a medical floor, the operating room or perhaps kept for observation.

Beyond medical expertise, however, working in the Emergency Department requires a large dose of compassion to cope with the needs of patients who rely on the Emergency Department for basic care for their chronic conditions such as asthma,  and social services because they lack a place to live or have no means of support.   Perhaps they need to detox from alcohol or have mental health issues.  “Emergency medicine demands the most intense involvement personally and intellectually,” observes Dr. Stephen Waxman. “Every area of clinical medicine is practiced, every emotion is taxed.”  (p 119)      

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In this book, Ivan Illich offers a harsh critique of health care as provided in western industrialized societies during the 1970s. However, he did not write this book as a health care expert. He was trained as a medieval historian and philosopher, and taught the history of friendship and the history of the art of suffering. Indeed, he admitted:  “I do not care about health.” (p. i) And yet, he could have written the same critique 40 years later.  

What brought Illich’s attention to health care was his broader interest in how modern responses to societal level challenges become counterproductive and even harmful:

The threat which current medicine represents to the health of populations is analogous to the threat which the volume and intensity of traffic represent to mobility, the threat which education and the media represent to learning, and the threat which urbanization represents to competence in homemaking. (p. 7)

Illich’s general thesis is that health care can work against the healing people seek from it, that health care can be as pathogenic as disease, and that health care can expropriate health. Health care is a nemesis to its subjects, he asserted, because it is “a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.” (p. 275)  

Illich builds his argument around the concept of iatrogenesis, which he differentiates into three categories: 1) clinical iatrogenesis, 2) social iatrogenesis, and 3) cultural iatrogenesis, each of which is given a separate section in the book.

Clinical iatrogenesis is the harm done to people as the result of actions taken to restore health or prevent illness, such as an adverse drug event, a hospital-acquired infection, or perforated bowel from a screening colonoscopy. Illich characterizes clinical iatrogenesis as it is understood and used in biomedical circles, but he brings a particular poignancy to it when he refers to “remedies, physicians, or hospitals [as] the pathogens, or ‘sickening’ agents” at work. (p. 27)  

With social iatrogenesis, Illich is referring to the harm societal arrangements for health care can inflict on people it’s meant to help. These arrangements comprise hospitals, physicians, health care product industries, insurers, and government agencies. The net effect of their actions is to standardize health care, and in Illich’s view, standardizing health care amounts to the “medicalization of life.” The more life is medicalized, the more people are forced to operate under the influence of organized health care, “when all suffering is ‘hospitalized’ and homes become inhospitable to birth, sickness, and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledegook; or when suffering, mourning, and healing outside the patient role are labeled a form of deviance.”
(p. 41)  Harm results to people whose ideas of what constitutes illness and whose preferences in the management of their illnesses do not match up with standardized health care. They could be harmed by treatments they don’t think they need, such as drugs to blunt grief, or in the ways they do not prefer, such as in a hospital. Thus, in social iatrogenesis, the social arrangements of health care are the pathogens.  

Before the social movements and transformations produced standardized health care, people of various cultures coped and adjusted in their own ways to the suffering they experienced. Illich’s cultural iatrogenesis occurs when societies capitulate to “professionally organized medicine [that] has come to function as a domineering moral enterprise that advertise industrial expansion as a war against all suffering.” (p. 127)  Illich is not saying that suffering is good and should be preserved, but rather that societies coming under the control of industrialized health care suffer more and suffer in ways they no longer have the authority or will to manage. Cultural iatrogenesis also manifests when professionally organized medicine supplants community responses to health problems people in that community experience: “The siren of one ambulance can destroy Samaritan attitudes in a whole Chilean town.” (p. 8) He elaborates on how cultural iatrogenesis works against people with examples involving treatment of pain, creating and eliminating diseases, and death and dying. 

Illich’s thoughts on countering the counter productivity of industrial health care take up the last section of the book. He does not propose tearing down organized health care, but rather getting it to where “health is identical with the degree of lived freedom,” because “beyond a certain level of intensity, health care, however equitably distributed, will smother health-as-freedom.” (p. 242)  Illich is beseeching organized health care to leave life less medicalized so as to leave more room for people to decide themselves if their challenges are a matter of health or not, and how they would prefer to manage them when health care may have a role. To this end, he concentrated this section of the book mostly on the political responses required to restore “freedom and rights” people ought to have to manage their health.  

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The Knick was inspired by the Knickerbocker Hospital, founded in Harlem in 1862 to serve the poor. In this 20-part TV series spread out over two seasons, the fictional Knick is somewhere in the lower half of Manhattan around 1900. The time covered during the series is not marked in any distinct way. The characters don’t age much, and although fashion and customs remain static during the series, the scope and significance of advancements that come into play were actually adopted over a longer time than the episodes cover.   

The series builds on some known history. The central character, the chief surgeon Dr. John Thackery, is modeled on a famous surgeon of the time, Dr. William Halsted, in both his surgical adventurism and in his drug addictions. The character Dr. Algernon Edwards, who is an African-American, Harvard-educated, and European-trained surgeon, is based in part on Dr. Louis T. Wright, who became the first African-American surgeon at Harlem Hospital during the first half of the 20th century.  

Storylines of human drama and folly run through the series. Among them are medical cases both ordinary and bizarre, heroic successes and catastrophic failures, loves won and lost, gilded lives and wretched existences, honor and corruption, racism and more racism. Within and around these storylines are the scientific, medical, and industrial advances of the period, as well as the social contexts that form fin de siècle hospital care and medical research in New York City.  

Some of the industrial advances we see adopted by the hospital include electrification, telephone service, and electric-powered ambulances. We see that transitions to these new technologies are not without risks and catastrophes: patients and hospital staff are electrocuted, and when the ambulance batteries died -- a frequent occurrence-- many of the patients they carried died, too.

Medical advances integrated into various episodes include x-rays, electric-powered suction devices, and an inflatable balloon for intrauterine compression to stop bleeding. Thackery is a driven researcher taking on some of the big problems of the day, such as making blood transfusions safe, curing syphilis, and discovering the physiologic mechanisms of drug addiction. We see how he learns at the cost of his patients, or rather his subjects. We also glimpse movements directed at population health. For example, epidemiological methods are applied to find the source of a typhoid outbreak, which drew from the actual case of Mary Mallon (aka, Typhoid Mary). Shown juxtaposed to the advances epidemiology was then promising is the concurrent interest that was rising in eugenics and its broad application to control for unwanted groups. Research ethics and regulations were a long way off.

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The subtitle is accurate enough: “A Memoir of a Family and Culture in Crisis,” although the author J.D. Vance is, in fact, the focal point of view throughout, from his childhood to his success as an adult. Few young people made it out of the hills to enjoy stable and successful lives, but J.D. was one of them, earning a degree at Ohio State University, then a law degree at Yale. While recounting his life, he also describes his relatives and neighbors, and he interprets the many dilemmas of his hillbilly culture. 
 
Vance was born in 1984 and grew up in Jackson, Kentucky, a poor town following the collapse of coal mining. His family was beset with poverty, alcoholism, mental instability, and more. His mother had nine miscarriages and suffered from addictions; she had multiple husbands. The culture around him suffered from domestic violence, drug abuse, hoarding, unemployment, honor defended by fists, knives, or guns, as well as bad financial habits, bad diets, obesity, lack of exercise, sugary drinks, dental problems, and what he calls “emotional poverty.”  There was welfare abuse and, in general “a chaotic life.”  He credits his grandparents, other relatives, various teachers and professors for supporting him, guiding him, and comforting him when he was hurt, angry, and/or confused.  

Like many other hillbillies, J.D. moved some hundred miles north into southern Ohio, where steel companies provided jobs—that is, until they closed, like many other employers in the Rust Belt. There also, hillbillies were left without income and social problems increased. Stores and restaurants closed. Payday lenders and cash-for-gold shops took their place. Drug dealers and users took over empty houses.  

After high school, Vance joined the Marines. He credits the military for teaching him discipline, persistence, and for developing his self-respect. For his success at Yale, he thanks his professors, his girlfriend (later wife), and classmates for helping him understand customs of New England society. One example: he leaves a banquet to call his girlfriend; she instructs him on how to handle the nine pieces of unfamiliar silverware surrounding his plate.  

The last three chapters (11, 12, 13) and the conclusion analyze his experience on more conceptual terms, including the “social capital” prized by the the New England world, social instability of the culture he was raised in, and “adverse childhood experiences” (or ACEs), the psychologists’ phrase for the damaging events children experience in a culture of poverty, violence, and limited futures. He writes that governmental child services have policies that don’t understand the important roles of aunts, uncles, and grandparents in subcultures that rely on extended families.  Indeed, faithful to his mother, he, as an adult, provides specific help to her. 

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This ambitious novel presents unusual events ten years after an international adoption.  Because of the Chinese one-child policy, Chinese peasant woman Xiao Lu abandons her second daughter Chun in a rural market, knowing that the child will be sent to an orphanage. An American couple adopt the child, calling her Katie. As a celebration for Katie’s tenth birthday, they return to southwest China, hoping to meet the birth mother.  

In a series of unusual events, they find Xiao Lu, and it is, at first, a joyous event. Troubles mount, however, as the birth mother wants Katie to stay with her, and Katie feels a mystical bond between them. Xiao Lu, having left her husband, now lives as a hermit in a hut on the slopes of The One Hundred Mile Mountain. She sweeps the 100 steps of The Elephant Temple daily and practices calligraphy in her hut.  

Pep and Clio Macy, having married late, could not get pregnant. The novel satirizes them as aging Yuppies, spoiled and materialistic. Clio wears a Movado watch worth hundreds if not thousands of dollars. The family’s cockerpoo has been boarded at home. Katie dislikes being the only Chinese American in her private school.  

After the birth mother has been found, the mood of the book changes. Xiao Lu wants her child returned, and the Macys fear that they are in danger. In the last 100 pages, nature itself attacks the Americans with snakes, monkeys, bats, a huge millipede, and even the weather. Pep is injured and receives rough, traditional medical treatment from a monk; it appears to be effective, however, in healing his heart physically and spiritually—a resonance with the book’s title. Katie becomes more and more like Xiao, learning calligraphy and some Chinese language. When Xiao is grievously injured by the monkeys, the Macys effectively care for her, and previous conflicts are resolved.

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The collection is prefaced and named for a poem by Walt Whitman, The Wound Dresser, annotated in this database by Jack Coulehan. In “On Reading Walt Whitman’s ‘The Wound Dresser’” Coulehan sees Whitman as a nurse tending the Civil War wounded, and, while using some of the words and language of Whitman’s poem, imagines himself moving forward in that created space of caring for patients: “You remain / tinkering at your soldier’s side, as I step / to the next cot and the cot after that.” (p. ix) The poem introduces us to all the ‘cots’ of the book – where we step from patient to patient, through history and geography, and through the journey of medical training.   The book is comprised of 4 sections without overt explanation, although there are 4 pages of Notes at the end of the book with information about select individual poems. In general, the themes of the sections can be described as: 1.) clinical care of individual patients and medical training; 2.) reflections on historical medical cases, reported anecdotes or past literary references; 3.) meditations on geographically distinct episodes – either places of travel or news items; and 4.) family memoir, personal history and the passage of time.   Many of the poems have been previously published and a few are revised from an earlier chapbook. Notable among the latter is “McGonigle’s Foot” (pp 42-3) from section 2, wherein an event in Philadelphia, 1862 – well after the successful public demonstration of anesthesia was reported and the practice widely disseminated, a drunk Irishman was deemed unworthy of receiving an anesthetic. Although it is easy to look back and critique past prejudices, Coulehan’s poem teaches us to examine current prejudices, bias and discrimination in the provision of healthcare choices, pain relief and access to care.   There are many gems in these 72 poems. Coulehan has an acute sensibility about the variety of human conditions he has the privilege to encounter in medical training and clinical practice. However, one of the standouts for me was “Cesium 137” based on a news report of children finding an abandoned radiotherapy source (cesium) in Goiania Brazil, playing with the glowing find and suffering acute radiation poisoning. He writes: “the cairn of their small lives / burst open…their bodies vacillate and weaken / hour by hour, consumed by innocence / and radiant desire.” (p. 68).   Following another poem inspired by Whitman, Coulehan concludes the collection with a sonnet “Retrospective.” He chronicles a 40-year career along with physical aging, memories of medical training “etched in myelin,” and the search for connection across that span of career including, “those he hurt, the woman / he killed with morphine, more than a few he saved.” Ultimately, he relies on hope with fitting understatement: “His ally, hope, will have to do.” (p. 97)

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This monograph is an important contribution—along with the Health Humanities Reader (2014)—to the burgeoning field of health humanities, a new academic field and the presumed replacement for (and expansion of) medical humanities. While the medical humanities included philosophy, literature, religion, and history, health humanities includes many more disciplines, and the creative arts.
This book is dense with theory and abstraction, but it imaginatively and intelligently promotes the notion that health is a larger and more useful concept than disease, which dominates and limits standard medicine. 

Five authors are listed for the book as a whole; none are attributed specifically to any of the eight chapters.
 
The first chapter “Health Humanities” promotes health humanities as an expansion of medical humanities to include more people (including unpaid caregivers and patients), social and national well-being, and the arts, such as dance, music, and visual art. We need to consider wider ranges of meaning, agency, and patients’ varying life stories. Unpaid caregivers have been neglected, even though “the majority of healthcare as it is practiced, is nonmedical” (p. 13). Medicine per se has been too science-based and too disease oriented, but critical theory and the arts can be “enabler[s] of health and well-being” (p. 19) with many applications to hospitals, clinics, homes, and neighborhoods.

“Anthropology and the Study of Culture” describes a wide range of inquiry, both worldwide and throughout human time, including rituals, conceptions of disease, health, death, and impacts for patients. Some cultures believe in spirit possession. The Chinese have worked with qi (life energy) for millennia. Cultural studies look at popular media, spiritual perspectives, also local and subcultural values.
 
“Applied Literature” discusses pathographies, including mental illness (for example, self-harm); it reviews concepts from Rita Charon and describes how reading groups can promote well-being. Literature expands our understanding of humans well beyond the biomedical gaze. Closely related, “Narrative and Applied Linguistics” reviews notions from Osler, Barthes, Bruner, Propp, Frank, and others. Patients want, beyond technical expertise, healthcare personnel who will help them co-create an enabling narrative. New techniques in linguistics include analysis of a corpus of usage, for example, teen language, thereby gaining approaches to young patients who cut themselves.

At 23 pages, the longest chapter is “Performing Arts and the Aesthetics of Health.” It posits that all arts are uniquely human because they are relational, aesthetic, and temporal (with time in a kairos sense, not just chronos). The arts fit into health practices, which also share the same three qualities. The arts promote coherence, agency, communication, expression, and social wellbeing, traits that are described specifically in music, dance, and drama. Similarly, the next chapter “Visual Art and Transformation,” promotes this particular art, whether elitist or popular, as communicative and transformative. The making of art can be healing. 

“Practice Based Evidence: Delivering Humanities into Healthcare” argues against Evidence Based Practice and its limitations. Instead of Randomized Controlled Trials, smaller, more qualitative studies may be more accurate and useful. Practice Based Evidence (and feminist and postmodern approaches) all create wider and deeper notions of validity.

“Creative Practice as Mutual Recovery” suggests that caregivers, whether professional or lay, also find healing as they deliver care.

In “Concluding Remarks” we read, again, that  “the majority of health care and the generation of health and well-being is non-medical” (p. 153). Medicine and medical humanities are “too narrow a bandwidth,” but health humanities can support all caregivers, various institutions (including schools), self-care, and complementary medicine.   

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The therapeutic benefits of music are well known, but the theory that music might be harmful to our health, unless it is so obviously loud it injures our eardrums, comes as a surprise.  In this volume, historian of medicine James Kennaway traces the idea of pathological music from antiquity to the present.  The book’s introduction considers whether music really can create illness, whether it be of a physiological or a psychological nature.  We learn, for example, of arrhythmias and seizure disorders that are set off by music, not to mention the so-called Stendhal Syndrome, a psychosomatic reaction to great works of art.

The second chapter describes how, during the 18th century, disease was thought to result from excessive stimulation of the nerves, and how that created a theoretical framework for the “medical dangers of music” (p. 23) as being rooted in the nervous system. The example of the glass harmonica is given. This musical instrument, invented by Benjamin Franklin, had its status elevated when Mozart composed two pieces for it.  However, its success became its undoing, as it was feared the tones would “make women faint, send a dog into convulsions, [and] make a sleeping girl wake screaming through a chord of the diminished seventh” (p. 45). Special gloves were devised so that a performer might, by avoiding direct contact with the apparatus, spare his nerves. 

In the following chapter, Kennaway explores how Wagner dominated 19th-century discourse on pathological music in that his work’s eroticism and novel harmonies were thought to produce neurasthenia (a popular catch-all term for an array of anxiety disorders). Listeners were brought to an unhealthy state of ecstasy, and singers, being driven to the abyss, went insane. Women who had recklessly allowed themselves to become “Wagnerized” were punished with a “lack [of] children, or, in the most bearable cases, men” (p. 74).

Moving into the 20th century, the author describes how ideas about pathological music acquired a political connotation.  In Germany, the perceived threat of avant-garde Jewish composers (eg. Schoenberg) to public health culminated in the so-called Degenerate Music exhibition of 1938. And in  the United States, African American-influenced jazz was credited with the power to “change human physiology, damaging the medulla in the brain” (p. 121).

Finally, the book concludes in the present day with music for brainwashing (e.g. a consideration of whether subliminal messages hidden in rock songs could lead to suicide), and the use of painfully loud or abrasive music as sonic weapons in warfare, or for torture.  The author’s verdict is that the notion of music as bad for your health, though emerging in new forms, is more topical than ever.

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This short but complex book assesses the many, current risks to all life on earth and considers some avenues for repair that may provide hope for the future. E. O. Wilson, a distinguished scientist, describes how all life on earth is inter-related. With a long view to the past and a wide view of the present—from microscopic creatures to humans—Wilson praises our planet’s biodiversity and warns of the dangers that may cause it to collapse; these dangers are human-related. Humans are an apex predator, smarter than all other creatures, but we are also too numerous, using too many resources, and causing various pollutions, including global warming. The health of the world and the health of all its creatures—humans included— are, for better or worse, interlinked forever.   
A Prologue warns that we are playing an “end-game” with the earth. To avoid a point of no return from mass extinctions, Wilson proposes a bold plan of setting aside one-half of the earth in reserve in order to stabilize the survival of humans.  

Part I, “The Problem,” describes the damage to our planet, on a par with the Yucatan asteroid 65 millions years ago, the so-called Fifth Extinction. We live in a narrow biosphere threatened by dying species, invasive species, collapse of interdependency, pollution of air, land, and water, loss of the commons, overhunting, human population growth, and outright habitat destruction (including the many impacts of climate change). He states, “the Sixth Extinction is under way” and “human activity is its driving force” (p. 55).   

Average time for recovery from each of the five previous extinctions is 10 million years. 

Self-centered humans do not understand the vast complexity of nature, including the many species not yet studied. He imagines far-distant geologists observing, “What a terrible time it was for people, and for the rest of life” (p. 9).  

Part II, “The Real Living World,” criticizes some conservationists who see nature in service to humans. Wilson says we are not owners of nature but stewards. He describes the abundant life of the Great Smoky Mountains National Park and a typical seashore as well as the extinction of the Ivory-Billed Woodpecker. Wilson contacted “eighteen of the world’s senior naturalists,” asking for suggestions for the “best reserves” to shelter “plants, animals, and microorganisms” (p. 135). Fifteen pages lovingly describe their recommendations of 33 places around the world. He concludes that “a great deal of Earth’s biodiversity can still be saved!” (p. 136).  

Part III, “The Solution” states, “The only solution to the Sixth Extinction is to increase the area of inviolable natural reserves to half the surface of the Earth or greater” (p. 167). Wilson reviews crises of water and food, and he warns against “self-inflicted disaster” that could wipe out most species by the end of this century. He provides two examples of restoration projects, the long-leaf pine lands in Florida and Gorongosa National Park in Mozambique. He believes the population bulge to ten billion people will be temporary.            

Wilson rejects geo-engineering of the oceans or the atmosphere as well as a proposed use of a passing asteroid. He argues that synthetic biology has promise for improving our brains for moral reasoning and ecological understanding. We need altruism (all working for all) and biophilia (deep love of nature).

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