Made to Care For Those Left Behind, This Hospital Leads the Way

THE PEOPLE’S HOSPITAL: Hope and Peril in American Medicine, by Ricardo Nuila

In 1963, the Dutch writer Jan de Hartog moved to the United States to teach a course at the University of Houston and began volunteering at Jefferson Davis, a public charity hospital in the city’s mostly Black Fourth Ward.

What de Hartog saw at that hospital became the basis of his scathing 1964 book, “The Hospital.” Along with the slap-in-the-face insult of Black residents forced to seek care at a facility named after the president of the Confederacy, the place was, in de Hartog’s words, a “monument of misery.” As he walked the overcrowded corridors of the hospital, on floors slippery with vomit and blood, he saw patients in various states of undress, some in wheelchairs, a mass of “human wrecks, sagging, hopeless personifications of utter misery.” It was the smell that shocked him most. He compared it to the foul odor that had hit him when, after World War II, during which he had been part of the Dutch resistance, he encountered the returning inmates of Nazi prison camps: “the all-pervading, overpowering stench of poverty, sickness, neglect, unwashed feet, unwashed clothes, foul breath, the stench of vomit and diarrhea.” He learned that in Houston it had a name: the “J.D. smell.”

In “The People’s Hospital,” Ricardo Nuila, a practicing physician and associate professor at Baylor College of Medicine, focuses on Ben Taub, the hospital that succeeded Jefferson Davis as Houston’s publicly funded flagship. But rather than dwelling on the horrors of a facility, Nuila deconstructs the deplorable inequality that creates the need for this, the largest safety-net hospital in what has become one of America’s largest and most diverse cities, in the state with the nation’s biggest population of uninsured.

Ben Taub is one of 31 entities that make up Texas Medical Center, the largest concentration of health care facilities in the world, but it is the primary one where health care is explicitly considered a human right — where anyone can walk through the doors and receive care, regardless of ability to pay.

At the core of “The People’s Hospital,” Nuila, a Houston native who has spent more than a decade as a medical student, resident and now attending physician at Ben Taub, asks a simple but profound question: “Why do some people benefit from health care in America, while others are excluded?” His answer is equally simple: Because the principal goal of the American health care system is to make money, period. Other things, like preventing illness and empowering people, can — and do — happen, but only after the first goal is met. He also offers what seems like an audacious idea: that Ben Taub should serve as a model for change.

Throughout “The People’s Hospital,” Nuila hammers home this central thesis. He unbraids the interlocked strands of hospitals, health insurance companies, Big Pharma and profit-minded physicians — what he calls “Medicine, Inc.” — all unified in the purpose of solving sickness through the mechanism of business.

He humanizes his points in meticulous and compassionate detail through focusing primarily on the stories of five Ben Taub patients. So many medical narratives center on the ugly endgame: very sick people at their worst — frightened and alone, in paper hospital gowns, their bodies failing them, sometimes suffering from dementia brought on by fear and the trauma of hospitalization. They appear as case studies, without back stories, community, family. Nuila, a skillful writer whose fiction has appeared in McSweeney’s, Guernica and the “Best American Short Stories” anthology, instead takes the time to work backward as he describes the plights of people he has cared for.

He begins with Stephen, the manager at a burger chain who enrolled in a company insurance plan so bare-bones that he had to prepay the ER where he was diagnosed with cancer. There is Ebonie, a Black mother of seven whose high-risk pregnancy nearly caused her to become a statistic of this country’s maternal mortality crisis. Christian, a healthy college student, chose not to buy into the health insurance offered at his retail job, then spent months searching for a diagnosis for crippling knee pain, eventually traveling to Mexico for treatment. Geronimo is a 36-year-old with liver failure as a result of hepatitis C and diabetes, whose skimpy disability check disqualified him for Medicaid — and put him just out of reach of a lifesaving transplant. Finally, Nuila introduces us to Roxana, an immigrant from El Salvador, who awoke from a cancer-related coma with gangrene so severe that her limbs looked like withered, charred wood. Without insurance or a green card, she spent months trying to find a physician to amputate her arms and legs.

Nuila comes from a family of doctors. His grandfather may have been the first Salvadoran doctor to earn a public health degree at Harvard. But after graduating, he returned to El Salvador to start a pediatrics practice. His son, the author’s father, immigrated to Houston, where he opened an OB-GYN practice, sharing office costs with his brother.

Even as a child, Nuila witnessed the daily balance his father struck between serving patients’ needs and running a business. By the time Nuila started medical school in 2002, his father could no longer afford to treat uninsured patients, turning more and more away. To return to his roots as a healer, the elder Nuila volunteered once a month at Ben Taub.

The author initially considered joining the family practice, and the friction between a pragmatic father with a booming private business and a son working with impoverished, uninsured patients provides a sometimes tense through-line. It’s not unusual for ambitious medical students and young physicians to make pit stops at places like Ben Taub — “an
excellent classroom” where the diseases described in textbooks come to life. Nuila explains that his experience as a student at Ben Taub made him a better doctor and burnished his C.V. But rather than move on to Harvard or the National Institutes of Health or his father’s practice, Nuila stayed — and made treating the most marginalized patients his life’s work.

He makes a counterintuitive case for viewing the resource-choked Ben Taub as a model for a more equitable health care system. If medicine — and by extension, healing — is an equation of science, cost and people, Nuila sees Ben Taub, even with the limitations that no safety-net hospital can overcome, as a coming-together of science and people, without the prioritization of money, where no person is unworthy of care and where providers make decisions based more on medical necessity than on cost.

As both writer and doctor, Nuila finds inspiration in Anton Chekhov, who worked as a physician even as he wrote short stories and plays. Less known, Chekhov treated some of Russia’s poorest, sickest people. Before he died in 1904 — of tuberculosis potentially contracted from a patient — Chekhov advocated changing a health care system that ignored human suffering. Nuila offers “The People’s Hospital” as a continuation of this call to action, imploring more people to act to alleviate human suffering — with government, not charity, taking up this work.

Linda Villarosa is a contributing writer for The Times Magazine whose work focuses on race and health. She is the author of “Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, which was one of the Book Review’s 10 Best Books of 2022.

THE PEOPLE’S HOSPITAL: Hope and Peril in American Medicine | By Ricardo Nuila | 370 pp. | Scribner | $24.99

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