The Hospital: Life, Death and Dollars in a Small American Town

Alexander, Brian

Primary Category: Literature / Nonfiction

Genre: Treatise

  • Date of entry: Jul-12-2021
  • Last revised: Jul-14-2021


Native Ohioan Brian Alexander cares a lot about his state and its many economic problems, especially as they impact healthcare. For this book, he’s an on-the-ground reporter covering the events in and around a hospital in the small town of Bryan from 2018 to 2020. He is also an in-depth interpreter, analyzing the many dilemmas of this small hospital and emphasizing that these represent parallel problems of social justice for all of contemporary American healthcare.  An opening chapter reviews some of the difficult history of this area, including economic collapse, lack of public health, lack of health insurance, and collapse of jobs in supply chains for Detroit.           

While the timeline of the story is short, it has wide breadth in local and national issues. These are illustrated by the stories  of specific people. Marc Tingle, a local contractor has a heart attack; his wife falls ill and is diagnosed with cancer. Medical bills mount up. Marc has a second heart attack and a stent inserted. He, like many others receives “rescue” medicine, not preventive healthcare, due to social or economic issues beyond their control. Similarly, we read about Keith Swihart, overweight and diabetic. He has a foot ulcer that requires surgery and later partial amputation. He has eye problems that progress to near blindness. Valerie Moreno injures her back at work but does not report it to the company, considering herself tough, but she must have spine surgery. After being laid off, she has part-time jobs, money problems, and turns to OxyContin pills. These are dramatic and painful stories.  

Many families make “just enough money to disqualify themselves…from Medicaid, but not enough to afford coverage offered by an employer or via the Affordable Care Act” (p. 242).            

Such patients illustrate a deadly whirlpool of issues: lack of routine medical care, inadequate health insurance, no national health program, a collapsed economy with no good jobs or prospects of advancement, poor nutrition, pervasive poverty, racism, sexism, and more.           

Amidst all this, we follow Phil Ennen, the CEO of this hospital (CHWC--for Community Hospitals and Wellness Centers) in Bryan. He wants to rely on his local, traditional values of “we can fix this,” but now he must confront the threats of national hospital chains, the need to cut staff and services, and the seductive lures of adding for-profit and high-tech services. Eventually, he sees no path forward and accepts the board’s invitation to retire. His replacement will have all the same problems.           

A closing section sees the arrival of Covid-19, a threat to this hospital and, of course, the nation at large. Alexander writes, “the virus seeped into the fault lines created by American pathologies. The country had changed from being an ongoing project to improve democratic society and live humanistic ideals to being a framework for fostering corporate profit” (p. 268).  


This is a powerful and insightful book. Its power comes from several resources that Alexander skillfully uses.  

First are the literary techniques. He presents memorable characters in various forms of distress.  There is suspense in the plot lines for both the characters and the hospital. He writes vivid descriptions of scenes in hospital ERs, at wrecks on highways, even in tense committee meetings. His style, clear and varied, pulls the reader along. His material reflects his journalistic skills in interviewing, imagining questions to answer, attending meetings, and riding along with EMS personnel. Further, the 17 pages of Notes show careful research into government documents, web sources, legal, academic, and medical resources, economic studies, print media, company reports, and more.   

Next is Alexander’s gift for analyzing and interpreting his material, looking for the deep causes, and overarching values in contemporary America. He effectively explores larger social values, critiquing consumerism, materialism, capitalism, and the pernicious effects on society of divisions by race, age, sex, education, and wealth. He notes the effects of the mistrust of science and government. He analyzes economic factors such as the power of private equity and of outright and pervasive greed that have created sharp divisions of wealth in America with dramatic impacts on health care.   

Alexander describes and interprets many interlocking features of contemporary American medicine, vividly showing us that our health care is inadequate, especially for poor people. During the period covered in the book, despite our wealth as a country, “the United States had the worst record of Covid-19 response in the industrialized world” (p. 275).  Alexander’s descriptions and research support his major and recurring theme: America is sick (pp. 10, 133, 247). The book is not only insightful but also startling: it provides a grim and disturbing picture of one hospital, of American healthcare and medicine, and of America as a country.   


St. Martin's Press

Place Published

New York



Page Count